Permit .
a CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2007 - 00068
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 3/14/2007
PARCEL: 25101 DA - 00800
SITE ADDRESS: 07105 SW VARNS ST 100 ZONING: C -P
SUBDIVISION: VARNS ACRES LOT: 011 JURISDICTION: TIG
PROJECT: VARNS STREET BUILDING
Project Description: .1 EDU increase.
TENANT NAME: VARNS STREET BUILDING
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.1
TYPE OF USE: CMS NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
SYMONDS EVANS & COMPANY PC
7105 SW VARNS RD SUITE 200 Description Date Amount
TIGARD, OR 97223
[SWUSA] Sewer Connection Fee 3/14/2007 $270.00
Phone: 503 - 597 -7350
Total $270.00
Contractor:
REQUIRED ITEMS AND REPORTS
Contact #:
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.
4
Issue • / / ,�.' Permittee Signature:
Call 503.639.4175 by 7:00 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 # 2S101 DA -00800
P ,
Tenant Name: Varns Street Building This SWR# 2007 -00068
Site Address: 7105 Sw Varns St This PLM# 2007 -00105
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off # s count N value H 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
- 3inch 5 0 0 0 0 0
- 4inch 6 0 0 0 0 0
- Car Wash Dm 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) 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 1 2 1 2
Sink- Bar /Lavatory 2 0 0 0 0 0
- 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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 _ 0 0 0 1 2 1 2
Current Fixture Value 2 divided by 16 = 0.1 Current EDU 1 EDU = $ 2,700
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) $ 270.00
Enter EDU Change Here 0.1
Notes:
Authorized Name /Signature: Debbie Adamski Date: 3/14/2007
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.
I. \ Building \ Forms \ SewerTallySheet.xls 02/02/07