Permit CITY TIGARD SEWER CONNECTION PERMIT
�y�, DEVELOPMENT SERVICES DATE SSU 5/118/2004 00143
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 09020 SW WASHINGTON SQUARE RD PARCEL: 1S126BC -01506
SUBDIVISION: 500 ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .2 edu increase
Owner: FEES
PORTLAND OFFICE ASSOCIATES Description Date Amount
BY TC PORTLAND, INC
8930 SW GEMINI DR [SWUSA] Swr Connectic 5/18/2004 $480.00
BEAVERTON, OR 97008 [SWUSA] Swr Connectic 5/18/2004 $0.00
Phone:
Total $480.00
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"
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.
Issued by. ' Permittee Signature: ,,j
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next busines d.
Accumulative Sewer Tally Parcel # ,2S126BC- 01506 - ' ..
Tenant Name:-- Taxtic This SW R# 2004 -00143 " . ,
r '
Site Address: 9020 Washington SQ.-Ste 500 This PLM# 2004- 00212 .'.'
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 L, 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 Drr 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 : _ 0 r - 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 -° z 0 , _ 0 0 0
- Bradley 5 _ 0 1' , , 0 0 0 0
- Commercial 3 �z 0 0 �1._ 3 1 3
- 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 - A " : 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 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) $ 480.00
Enter EDU Change Here 0.2
Notes:
Name i w ` z te -. c� Date: / a
Building Division f
Note: The property owner shall retain this record for sewer credit purposes. In the event of a credit, this
document stamped "ORIGINAL" shall serve as a credit voucher and must be submitted to the City of
Tigard Building Division to redeem credit towards future system development charges.