Permit CITY TIGARD SEWER CONNECTION PERMIT
411 DEVELOPMENT SERVICES PERMIT #: SWR2004 -00013
l j 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/16/04
SITE ADDRESS; 15822 SW UPPER BOONES FERRYRD PARCEL: 2S112DD -00701
SUBDIVISION: G I ON BUS. PARK 1I ZONING: I -
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: SPEC SPACE
USA NO: FIXTURE UNITS: 8
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .5 EDU increase. (1) lay and (1) toilet.
Owner:
FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [SWUSA] Swr Connect 1/16/04 $1,200.00
[SWUSA] Swr Connect 1/16/04 $0.00
Phone:
Total $1,200.00
Contractor:
Phone:
Reg #:
Required Inspections
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" Perm
•
Issu • by: ' ;� Permittee SignatureA
Call (503) 6 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally Parcel # 2S112DD -00701
Tenant N , e: sl3ec space This SWRA 2004 -00013
Site Address: 15822 SW Upper Boones Ferry Rd. Bldg. C This PLM# 2004 -00020
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 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 Drn 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) 48 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 - Bar /Lavatory 2 0 0 1 2 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 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 1 6 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 8 2 8
Current Fixture Value 8 divided by 16 = 0.5 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 8 divided by 16 = 0.5 over (under) $ 1,200.00
Enter EDU Change Here 0.5
Notes:
Signature „. i,e ��, . , if Date: / - /6 --+.
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.
is \Building \Sewer Tally \SewerTallySheet.xls 11/19/03