Permit I f CITY OF TIGARD SEWER CONNECTION PERMIT
4111 DEVELOPMENT SERVICES DATES PERMIT ED: 1 6/04 R2004-00010
---' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 09370 SW GREENBURG RD 205 PARCEL: 1S126DB-02800
SUBDIVISION: PP1991 - 018 ZONING: C -
BLOCK: LOT: 001 JURISDICTION: TIG
TENANT NAME: BERNARD BEUFFEL, MD
USA NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .3 EDU increase
Owner: FEES
FRANKLIN COMMONS ASSOCIATES
BY NORRIS + STEVENS Description Date Amount
520 SW 6TH STE 400 [SWUSA] Swr Connect 1/16/04 $720.00
PORTLAND, OR 97204 [SWUSA] Swr Connect 1/16/04 $0.00
Phone:
Total $720.00
Contractor:
Phone:
Reg #:
Required Inspections
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Perm
Issued by: : -' j /�/ �� Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed th • next • usiness day
Accumulative Sewer Tally Parcel # 1S126DB -02800
Tenant Name: Bernard BueTfel, MD This SWR #2004 -00010
Site Athiress: 9370 SW Greenburg Rd #205 This PLM# 2004 -00018
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 0 0 0
- 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 HP) 48 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 1 2 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 1 3 0 -1 -3
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 1 6 1 • 6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS _ 0 0 1 3 2 8 1 5
Current Fixture Value 5 divided by 16 = 0.3 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 5 divided by 16 = 0.3 over (under) $ 720.00
Enter EDU Change Here 0.3
Notes: �' n i
Sig nat e: ��� l_.Lp,J( inik_X116 Date: / /s
Bui ding 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.
is \Building \Sewer Tally \SewerTallySheet.xls 11/19/03