Permit CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2011 00157
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued:
Parcel: 2S112DA01400
Jurisdiction: Tigard
Site address: 15350 SW SEQUOIA PKWY 320
Project: Professional Eye Subdivision: 1996 -048 PARTITION PLAT Lot: 2
Project Description: .1 EDU increase. Sewer credits applied from PLM2010- 00338.
Contractor: Owner: PACIFIC REALTY ASSOCIATES
ATTN: N PIVEN
15350 SW SEQUOIA PKWY #300
PORTLAND, OR 97224
PHONE: PHONE: 503 - 624 -6300
FAX:
FEES
Description Date Amount
Specifics:
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: .1
Number of Dwelling Units:
Total $0.00
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 1.800.332.234•
Issued By: -' Permittee Signature: /
Call 50 =' 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.
Accumulative Sewer Tally
s , ?: Tenant Name: PROFESSIONAL EYE CARE (REVISED) SWR # SWR2011 -00157
-, Site Address: 15350 SW SEQUOIA PKWY #320 PLM # PLM2011 -00349
4 - Parcel #: 2S112DA01400
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 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 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:
- Lav /Bar - Non -Food Related 2 0 0 1 2 1 2
- 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 0.1 1.6
TOTALS 0 0 0 0 1 2 1 0.4
Current Fixture Value 0.4 divided by 16 = 0.0 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 0.4 divided by 16 = 0.0 over (under) $ -
Enter EDU Change Here 0
Notes: .1 EDU CREDITS APPLIED FROM PLM2010 -00388 TO CANCEL OUT FEES: ZERO BALANCE.
Authorized Name /Signature: BRANDEN TAGGART X2449 Date: 11/17/2011
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 \SewerTallySheet- 4500.xls 07/01/11