Permit I �
CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2009 -00019
T t GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/08/2009
Parcel: 2S 114AA00200
Jurisdiction: Tigard
Site address: 16285 SW 85TH AVE 403
Subdivision: DURHAM HALL BUSINESS PARK Lot: 0
Project: Souper Natural Pepper Heads
Project Description: Install (3) 2" floor drains, (1) floor sink, (1) mop sink, (2) 3- compartment sinks, (1) 2- compartment
sink, (1) hand sink.
Owner: FEES
SHIPMAN, W H LIMITED Description Date Amount
BY NORRIS & STEVENS INC, 621 SW Sewer Connection Fee 04/08/2009 $4,340.00
MORRISON STE #800
PHONE:
Contractor:
JAK NORTHWEST LLC
17114 NE 20TH ST.
VANCOUVER, WA 98684
PHONE: 360 - 772 -0957
FAX: 360- 828 -5988
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: 23
Number of Dwelling Units:
Total $4,340.00
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Issued By: _ .� = • Permittee Signature: C ' Q_V', -11 11 +■ l ( `c'n
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
• ' ' Accumulative Sewer Tally Parcel # 2s114aa00200
Tenant Name: Souper Natural Pepper Heads This SWR# 2009 -00019
Site Address: 16285 85th ste 403 This PLM# 2009 -00078
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 4 8 4 8
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 LIP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 5 15 5 15
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 9 23 9 23
Current Fixture Value 23 divided by 16 = 1.4 Current EDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 23 divided by 16 = 1.4 over (under) $ 4,340.00
Enter EDU Change Here 1.4
Notes:
Authorized Name /Signature: Loraine Sellers Date: 4/7/2009
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \ Building \Sewer Tally \Sewerl'allySheet- 3100.xls 06 /19/08