Permit ; , CITY OF TIGARD SEWER CONNECTION PERMIT
'- ' COMMUNITY DEVELOPMENT Permit #: SWR2011 -00099
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/14/2011
. Parcel: 2S110DB01700
Jurisdiction:
Site address: 15290 SW PACIFIC HWY
Project: Black Rock Coffee Shop Subdivision: 1996 -010 PARTITION PLAT Lot: 2
Project Description: 1.3 EDU's for new commercial manufactured structure.
Contractor: Owner: JESS WETSEL
10110 SW NIMBUS AVENUS SUITE B -9
PORTLAND, OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Inspection - Commercial 07/14/2011 $45.00
Sewer Connection Fee 07/14/2011 $5,330.00
Type of Use: CMS
Class of Work: NEW
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1.3
Total $5,375.00
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 -0090. You may obtain a copy of the rules or direct questions
to OUNC by calling 503 232.1987 or 1.800.332.2344.
Issued By: , /`� `�`� Permittee Signature: /,i?7
Call 503.639.4175 by 7:00 a.m. for the next available inspectio date.
This permit card shall be kept in a conspicuous place on the job site until c.mpletion of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # ;2S1.100B01700 " " ".
l 'enantZNaine'.B1ack, Kock' Coffec . ib' t a ^: *4a. ifs '
;.. , . a�_� .�.a <�� . � e, This SWR# (2011w= 0�0099�
Site ; Addres, :.15290 SW Pacific IIwg; ,. ',° : This PLM# 2011- 00200.: " ` i , s,,
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 r ;,„ 0 t k 0 N ; V: 0 0 0
Bath - Tub /Shower 4 x l 0 ° : ' 4 0 -. ,' 0 0 0
- Jacuzzi /Whirlpool 4 ., t 0 =, � 0 0 0 0
Car Wash - Each Stall 6 .4: 0 r� 0 x „ .., 0 s 4 4- 0 0 0
- Drive through 16 „,, t = ;', 0 , " "` 0 .: 0 0 0
Cuspidor /Water Aspirator 1 0 0 .A - 0 0 0
Dishwasher - Commercial 4 0 5 y l. 0 ' -1 0 0 0
Domestic 2 0 : 0 '' ''x 0 0 0
Drinking Fountain 1 e i r ,' 0 !« az :�4 _ 0 0 0 0
Eye Wash 1 a° Va ' ' 0 „; 0 ! 0 0 0
Floor Drain /Sink - 2 inch 2.,,n 0 „ a 0 � i ; 2' •.'' 4 2 4
- 3 inch 5 1 x ;tltl, , 0 ,, s' 0 ' :._1l 0 0 0
- flinch 6., 0N:ft 0 - ,- 0 0 0
- Car Wash Drn 6 . V;., - 0 - � ;,a„,�i ; 0 x � " 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 1 , 0 ? '' ` i ;, 0 0 . .t.1; 7 :, 1 ' 0 0 0
- Commercial (to 5 HP) 32 r: p ..x� 0 -4a 0 -';+ 0 0 0
- Industrial (over 5 I IP 42 l ', = 0 r. „� 0 ' ,f, t�° a + =s. 0 0 0
Ice Machine /Refrigerator Drain 1 0 - 0 0 0 0
Oil Sep (Gas Station) 6 ` ' 0 1 : 1,,, 0 ° ` 0 0 0
Rec. Vehicle Dump station 16 � .& -; i .s�, 0 .„,.i.,- 0 ;; "� � 0 0 0
Shower - Gang (per head) 1 '" 0 ,„ 0 s ? --,,l , 0 0 0
• -Stall 2 0 -, -: " ' " . i i- 0 „„ ;t' _.• 0 0 0
Sink - Bar /Lavatory 2 ' i ,,; 0 l „,' , 0 , 11i/ 2 1 2
Bradley 5 �� 0: k n c 0 r4, ° .a`' 0 0 0
" 2 `
— Commercial 3 - , ', 0 a� :: 0 ry ` '
fl � ' �� � � .2 6 2 6
.�°,,-
- Service 3 � .' 0 P 3 -= A 0 4 l _ 3 1 3
Swimming Pool Filter 1 1 *; 0 -x, - 0 0 0 0
Washer - Clothes 6 0 e 0 . ` 0 0 0
Water Extractor 6 : 0 p 0 • ' 0 0 0
Water Closet - Toilet 6 '' $`A = , _ 0 ,,, ` 0 ,, :::,1;,.:..., 6 1 6
Urinal 6 r' 0 ,_ _ 0 .. 0 0 0
Previous EDU County .`: 0 0
Capped EDU Credit A . „. „
0
TOTALS 0 0 0 0 7 21 7 21
Current Fixture Value 21 divided by 16 = 1.3 Current EDU 1 EDU = $ 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 21 divided by 16 = 1.3 over (under) $ 5,330.00
Enter EDU Change Here al'I 'SS , '
Notes: All demo credits previously used by Sonic Drive -In in 2010.
Authorized Name /Signature:. IDebbie' Adamsl i , . _,'” "' "''.4.5,=-1-= - '1' Date : 7/5 - r e . , 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:A Building \Sewer Tally \Sewer'1'allyShcet- 4100.xls 07/01/10