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Permit
Accumulative Sewer Tally Parcel # 1S135DD- 003301 Tenant Name: Zo -Ann Fabric This SWR$ 2005 -00220 Site Address: 11945 SW Pacific Hwy. This PLM# 2005 -00299 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 A 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 1 1 1 1 0 0 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 10 20 2 4 -8 -16 - 3 inch 5 0 4 20 2 10 -2 -10 - 4 inch 6 0 0 0 0 0 - Car Wash Dr 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 1 32 0 -1 -32 - Industrial (over 5 HP) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 4 4 0 -4 -4 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 4 8 5 10 1 2 - Bradley 5 0 0 0 0 0 - Commercial 3 0 6 18 0 -6 -18 - Service 3 0 0 1 3 1 3 Swimming Pool Filter 1 0 0 0 0 Washer - Clothes 6 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet 6 0 5 30 3 18 -2 -12 Urinal 6 0 1 6 1 6 0 0 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 36 139 15 52 -21 -87 Current Fixture Value -87 divided by 16 = -5.4 Current EDU 1 EDU = $ 2,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change -87 divided by 16 = -5.4 over (under) $ (14,040.00) Enter EDU Ch - • e Here -5.4 Notes: Authorized Name /Signature: Date: 9 /9 - Building Division Note: The property • 'er sh- the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher ich must be submitted to th - -,,Z ity of Tigard Building Division to redeem credits towards future system development charges. i:\Building \Sewer Tally\SewerTallySheet.xls 7/1/05 -.,.. ,.. A Building Division , Applicant Request for Permit Action C ;. W City of Tigard TO: CITY OF TIGARD, BUILDING OFFICIAL 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.639.4171 Fax: 503.598.1960 FROM: Applicant Name: NO r ` r c 1-t C (mil C Mailing Address: J 5WA./! City /State /Zip: V 0 1 0 Phone No.: 7 / Fax No.: ' L ASE TAKE ACTION CHECKED (✓) FOR THE FOLLOWING PERMIT: E CANCEL PERMIT APPLICATION. • REFUND PERMIT FEES. Permit No.: .1.0 (Z © -()C C) Type of Permit: J9A1� Site Address: t V ° a Subdivision: Lot No.: EXPLANATION: -- ,.(i_.t.,),<A i p,A/1--j } ils—ck:AJ . m j s - j,) a -- * (-) si_S ?et Reedezzia_Arit_ §1/ / 9-4444-2.i7,, c , c 7i1..404...., 4.64.„...1-6,:me e4. e2,-,.. Signature: , ,„, �� Date: 7/ G I /6 Print Name: { 9 'FOR OFFICE USE ONLY ' '' ' Route to Admin.: Date: i9Y1 () 5 By: ' Permit Canceled: Date: By: Refund Processed: Date: By: Cashier Receipt: Date: #: Amnt: $ Payment Type: Per: is \Building\Forms\RegPermitAction 09- 27- 04.doc