Permit CITY TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 -00141
I 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 4/25/2005
PARCEL: 1S126CA-01000
SITE ADDRESS; 09009 SW HALL BLVD 142 ZONING: C -
SUBDIVISION: WASHINGTON CIRCLE PLAZA LOT: JURISDICTION: TIG
Project Description: 3.5 EDU increase.
TENANT NAME:
CWS NO: FIXTURE UNITS: 56
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
WASHINGTON SQUARE PLAZA
BY THE CAFARO COMPANY Description Date Amount
P 0 BOX 422 [SWUSA] Swr Connection Fee 4/25/2005 $8,750.00
FLORHAM PARK, NJ 07932
Total $8,750.00
Phone:
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued byil? _ L . < J < < /! Permittee Signature: -
Call 503 - 639 -4175 by7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # 2S1y26G C)100
T4i1 ;$ 44 !,44*Pi k -.l ,. V 4 >.r. This SWR4200 0,QQt41
;S to ldtfi' Shill IONa ite , f4 i, This PLM# 2000 00 4 0 ., .. • k = ,
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
F
- Jacuzzi/Whirlpool 4 ; ,,, x 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16t 0 0S 0 0 0
Cuspidor /Water Aspirator 1 r,1 t �„ 0 , , 0 �. r >,, 0 0 0
6
Dishwasher - Commercial 4 0 k, 0 ,z 0 0 0
- Domestic 2 0 0 r 0 0 0
Drinking Fountain 1 0 ;.'1 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink 2 inch 2 0 0 2 H 24 12 24
s
- 3 inch 5 0 0 0 0 0
- 4 inch 6 s1 5 ' 0 0 ' 0 0 0
i2' r J.a '�. Y
- Car Wash Drn 6 avian �. „ x; 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 U ,, �„� ° , ;
0 0 „• 0 0 0
- Commercial (to 5 HP) 32 0 0 , 0 0
r
0
- Industrial (over 5 HP) 42 v x .` 0 l* 4 0 z x 0 0 0
Ice Machine /Refrigerator Drain 1 4 , 0 ,,, 0 s { � 1 1 1
Oil Sep (Gas Station) 6 Y ;x M r 0 gli 0 l'' : 0 0 0
Rec. Vehicle Dump station 16 titan 0 ' 0 Eidatal 0 0 0
Shower - Gang (per head) 1�, 0 r €, ; 0 i 0 0 0
- Stall 2 NU . x 0 ? r, 0 0 0 0
Sink Bar /Lavatory 2 0 fi r 4 4;.` 0 ;44 - ; , , , ,,, , , ,,: : ,/, 4,,, , ,,,,,.
4 2 4
- Bradley 5 $�3�' 0 v� ;i: 0 0 0 0
- Commercial 3 to ` x 0 per,
�, � 0 �, ,� � ` 15 5 15
Service 3 3 < z` 0 0 a�* 0 0 0
Swimming Pool Filter 1 Nc 2 0 r 3 3 4 0 � i�` 0 0 0
'' �
Washer - Clothes 6 , A 0 . 0 *� 12 2 12
Water Extractor 6 �� ,,s t • 0 ; 0 � y 0 0 0
Water Closet Toilet 6 f r .
� y Z 0 0 x f q 0 0 0
Urinal Snit" c 0 �,, 0 F .. 0 0 0
Previous EDU Count yy 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 22 56 22 56
Current Fixture Value 56 divided by 16 = 3.5 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 56 divided by 16 = 3.5 over (under) $ 8,750.00
Enter EDU Change Here egOtti
Notes:
Signature: , 9 ,�� i<i .aA.i�G Date: — 23 — Ci ' .--- '
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.
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