Permit CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2011 -00031
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/17/2011
Parcel: 1 S135BC01100
Jurisdiction: Tigard
Site address: 11131 SW GREENBURG RD
Project: Jump Sky High Subdivision: Lot: 0
Project Description: .8 EDU increase
Contractor: Owner: ROBINSON FAMILY TRUST
BY E LEE & EVELYN L ROBINSON TRS
PO BOX 91305
PORTLAND, OR 97291
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 02/17/2011 $3,280.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Numberof Dwelling Units: 1.9
Total $3,280.00
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 su ded for •re the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. hose rules are s: t '•rth in • ' R 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUN by calling 503.232.1 • :7 or .: ; S. 32.2344.
Issue By: %" Permittee Sign. ` �� � ."
Call 503.639.4175 by 7:00 a.m. for the next available inspect' •
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 # 1S135BC01100
Tenant Name: Jump Sky High This SWR# 2011 - 00031
Site Address: 11131 SW Grecnburg Rd This PLM# 2011 - 00054
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #5 values
Baptistry /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 - 1?,ach 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
Nye 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 I -IP) 32 0 0 0 0 0
- Industrial (over 5 I -IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 1 1 1 1
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 1 2 0 -1 -2
- Bradley 5 0 ,\ 0 0 0 0
- Commercial 3 0 0 2 6 2 6
- Service 3 0 0 0 0 0
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 MU Count 0 0
Capped MU Credit 0
'IOTA I,S 0 0 1 2 7 15 6 13
Current Fixture Value 13 divided by 16 = 0.8 Current EDU 1 EDU = S 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 13 divided by 16 = 0.8 over (under) S 3,280.00
Enter EDU Change Here 0.8
Notes: 1 sink is draining into 2" floor sink, so only counting the floor sink on this worksheet.
Authorized Name /Signature: Debbie Adamski Date: 2/16/2011
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.
1•\ Building \Sewer Tally AScwer'l'allyShcet -3600 xis 06 /25/08
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