Permit CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2011 -00126
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 09/14/2011
Parcel: 25101 DC04602
Jurisdiction: Tigard
Site address: 7291 SW TECH CENTER DR
Project: Pacific Recreational Products Subdivision: Lot:
Project Description: .1 EDU increase.
11/10/2011: REPRINT permit to add (1) additional fixture for a total EDU increase of .3. DLH
Contractor: PERLO CONSTRUCTION LLC Owner: MCCORMACK PROPERTIES LP
7190 SW SANDBURG ST 7190 SW SANDBURG ST
PORTLAND, OR 97223 TIGARD, OR 97223
PHONE: 503 - 624 -2090 PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 09/14/2011 $450.00
Type of Use: SF
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: 2
Number of Dwelling Units: .3
SEE T 19 — C77 1— /A/ t/'
rife- 4- J. r 77e' V }- _
Total $450.00
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: 1 ajt_ ! I . Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
CITY OF TIGARD FEE AND PAYMENT HISTORY
ill : _ 13125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
TIlGARD •-
SWR2011 -00126 - 7291 SW TECH CENTER DR, TIGARD, OR 97223
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due
Sewer Connection Fee 500- 0000 -25500 $1,350.00 $1,350.00 $450.00 9/14/11 Check 183915 $900.00
Totals for Fees $1,350.00 $1,350.00 $450.00 $900.00
Receipt # Payment Method Check # Payor: Receipt Date Receipt Amount
183915 Check 3780 McCormack Properties 09/14/2011 $450.00
LP
Total Payments: `450.0 —�
Balance Due: $900.00 )
--- .._..,.- m _y
Accumulative Sewer Tally REVISED
EFI; Tenant Name: PACIFIC RECREATIONAL PRODUCTS SWR # SWR2011 -00126
a R " Site Address: 7291 SW TECH CENTER DRIVE PLM # PLM2011 -00272
.TIGA p
Parcel #: 2S101 DC04602
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total 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 6 0 0 0 0 0
Garbage Disposal:
- Domestic (to 3/4 I -IP) 16 0 0 0 0 0
- Commercial (to 5 I -IP) 32 0 0 0 0 0
- Industrial (over 5 IIP) 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:
- Lay/Bar - Non -Food Related 2 0 0 2 4 2 4
- Bradley 5 0 0 0 0 0
- Com /Sery /Util - Food Related 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 EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 4 2 4
Current Fixture Value 4 divided by 16 = 0.3 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 4 divided by 16 = 0.3 over (under) $ 1,350.00
Enter EDU Change Here 0.3
Notes: REVISED PER WESTERN PLUMBING, ADDED (1) LAUNDRY TRAY INCREASING THE EDU FROM 0.1 to 0.3.
SEND INVOICE TO PERLO CONSTRUCl'ION FOR $900.00 ADDITIONAL FEES DUE.
Authorized Name /Signature: Dianna Howse Date: 11/10/2011
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. .
I:\ Building \ Sewer Tally \Sewerl'allySheet- 4500.xls 07/01 /11
•
City of Tigard
q Building Division
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2439 Fax: 503.598.1960
T l G A K U Inspection Line: 503.639.4175
Internet: www.tigard - or.gov
PAYMENT AUTHORIZATION FORM
Permit No. (if available): %i Q2. ; ) s 4
Job Site Address: _,St() %``CC, CIry °7 EEle
Project Name: ,e C' l/=' °Z% 4' i`0/v:(9 -e-
Credit Card Information:
I VISA n MasterCard
n Discover (Credit Card Account Number)
Expiration Date: •
Cardholder Name (on card):
Contact Phone No.: 4'%
Address for this card is: /- _ .6t
Zip code for this card is:
Electrical Trust Account Information: p 3 S7 � / 7 6 c
Trust Account (CCB) No.:
evc
Contractor Business Name:
Contact Phone No.:
I hereby give the City of Tigard permission to pay for the above referenced
permit with the credit card or electrical trust account number provided above.
Authorized Signature:
Name Printed:
Date:
Please FAX this completed and signed form to 503.598.1960.
To protect credit card information, do not email this form.
This form will be destroyed after your payment has been processed.
1:A Building \ Forms \PaymentAuthorization.doc 02/08/2011