Permit CITY OF TIGARD SEWER CONNECTION PERMIT
o • COMMUNITY DEVELOPMENT Permit #: SWR2012 -00082
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/27/2012
Parcel: 2S110DC00500
Jurisdiction: Tigard
Site address: 11455 SW SUMMERFIELD DR
Project: Schwindt Medical /Dental Office Subdivision: WILLOW -BROOK -FARM Lot: 17
Project Description: 2 EDU's. Demo credits from BUP2012 -00094 applied. (New building has total of 4 EDU's - 2 EDU credits = 2
EDU's charged.)
Contractor: Owner: CDBK PROPERTIES LLC
11565 SW DURHAM RD BLDG F 100
TIGARD, OR 97224
PHONE: PHONE:
FAX:
FEES
Description Date Amount
•
Specifics: Sewer Connection Fee 06/27/2012 $9,000.00
Sewer Inspection - Commercial 06/27/2012 $45.00
Type of Use: COM
Class of Work: NEW
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 2
Total $9,045.00
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 c- • • : 232.1987 or 1.800.332.2344.
Issued B GC' 'L ' 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.
Accumulative Sewer Tally
11 _'? , Tenant Name: Dr. Schwindt•Dcrital Office SWR # 2012 -00082
Site Address: 11455 SW Summcrfield • PLM # 2012 -00112
Parcel #: 2S110DC00500
Fixture Value P rev i ous 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 1 2 1 2
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink: - 2 inch 2 0 0 2 4 2 4
- 3 inch 5 0 0 2 10 2 10
- 4 inch 6 0 0 0 0 0
- Car Wash 6 0 0 0 0 0 •
Garbage Disposal: .
- Domestic (to 3/4 I -1P) . 16 ' 0 0 0 0 0
- Commercial (to 5 I -IP) 32 0 0 0 0 0
- Industrial (over 5 1-IP) 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 -hood Related 2 - 0 0 , 12 ' 24 12 24
- Bradley 5• 0- 0 - 0• 0 0
- Com /Scry /Util - Food Related 3 0 0 • 0 . 0 0
Swimming Pool Filter 10 0 . 0. 0 0
Washer - Clothes 6 0 -- 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 • 3 18 3 18
Urinal • 6 v 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 2 32
TOTALS 0 0 0 0 21 64 21 .32
Current Fixture Value 32 divided by 16 = 2.0 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 32 divided by 16 = 2.0 over (under) S 9,000.00
Enter EDU Change Here . 2
Notes: 5/9/12, per UB current billing rate is 2 DU's. Demo credits or 2 DU's from BUP2012 -00094 applied to this permit.
Authorized Name /Signature: Debbie Adainski ' Date: 5/9/2012 •
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. I f 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.
1: \ Building \ Sewer Tally \Sewer 1'allyShcet- 4500.xls 01/18/12 .