Permit I �� CITY OF TIGARD j • SEWER CONNECTION PERMIT
I , 1 COMMUNITY DEVELOPMENT 940,44 Permit #: SWR2012 -00161
TIGARD 13125 SW Hall Blvd.. Tigard OR 97223 503.718.2439 Date Issued: 07/30/2012
Parcel: 2S115BA02600
Jurisdiction: Tigard
Site address: 16230 SW PACIFIC HWY 140
Project: House of Bread Subdivision: 2004 -015 PARTITION PLAT Lot: 2
Project Description: 1.13 EDU increase. 9/5/12, reprinted to correct ASI info
Contractor: Owner: SN PROPERTIES PARTNERSHIP
1121 SW SALMON ST
PORTLAND, OR 97205
PHONE: PHONE:
FAX:
•
FEES
Description Date Amount
Specifics: Sewer Connection Fee 07/30/2012 $5,271.45
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
- Fixture Units:
Number of Dwelling Units: 1.13
Total $5,271.45
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. Tho rules. are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obt -'• a copy of the rules or direct questions
to OUNC calling 503.232. ::7 or 1.800.332.2344.
Issu d By: 0 ( Permittee Signat. �� (74.P
Call 503.639.4175 by 7:00 a.m. for the next available inspection • . te.
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 SEWER CONNECTION PERMIT
lq
° • - COMMUNITY DEVELOPMENT Permit #: SWR2012 -00161
T I GARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/30/2012
Parcel: 2S 115 BA02600
Jurisdiction: Tigard
Site address: 16230 SW PACIFIC HWY 140
Project: House of Bread Subdivision: 2004 -015 PARTITION PLAT Lot: 2
Project Description: TI
Contractor: Owner: SN PROPERTIES PARTNERSHIP
1121 SW SALMON ST
PORTLAND, OR 97205
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 07/30/2012 $5,271.45
Type of Use:
Class of Work:
Install Type:
Fixture Units:
Number of Dwelling Units:
•
•
Total $5,271.45
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 o. -in a copy of the rules or direct questions
to OUNC by calling 503.232.1987 or 1.800.332.2344. '
Issued By: Permittee Signature: / .
Call 503.639.4175 by 7:00 a.m. for the next available inspecti• • ;
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.
U PI -
a Tenant Name: House of Bread
Accumulative Sewer Tally SWR # 2012 -00161
C Site Address: 16230 SW Pacific Hwy #140 PL\I # 2012 -00197
Parcel #: 2S115BA02600
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Baptistry /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
Eve Wash 1 0 0 0 0 0
Moor Drain /Sink: - 2 inch 2 0 0 2 4 2 4
- 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 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 2 2 2 2
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:
- I.av /Bar - Non -Food Related 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Com /Serv/Util - Food Related 3 0 0 4 12 4 12
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 8 18 _ 8 18
Current Fixture Value 18 divided by 16 = 1.125 Current EDU 1 EDU = $4,665.00
Previous Fixture Value 0 divided by 16 = 0.000 Previous EDU
Change 18 divided by 16 = 1.125 over (under) S 5,271.45
Enter EDU Change Here 1.130
Notes:2 of the food prep sinks indirect drain to floor sinks, so only the food prep sinks arc calculated (did not include 2 floor sinks in the calculation).
Authorized Name /Signature: Debbie Adamski Date: 7/17/2012
Building Division
Note: The property owner shall retain the ORIGIN: \L 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 117 /111 /12 •