Permit r CITY OF TIGARD SEWER CONNECTION PERMIT
I� DEVELOPMENT SERVICES PERMIT #: SWR2005 -00270
��II 13125 SW Hall Blvd., T igard, OR 97223 503 - 639 -4171 DATE ISSUED: 9/2/2005
PARCEL: 1S12600-00300
SITE ADDRESS: 09312 SW WASHINGTON SQUARE RD ZONING: C -
SUBDIVISION: WASHINGTON SQUARE LOT: JURISDICTION: TIG
Project Description: 1 EDU increase.
TENANT NAME:
CWS NO: FIXTURE UNITS: 0
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
WASHINGTON SQUARE LLC Description Date Amount
BY THE MACERICH COMPANY
9585 SW WASHINGTON SQUARE RD [SWUSA] Sewer Connection Fee 9/2/2005 $2,600.00
TIGARD, OR 97223
Total $2,600.00
Phone: 503 639 - 8865
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
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 fo •w rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 thro 2h • r R 952-001-011i. You
may obtain copies of these rules or direct questions to OUNC by calling 503-246-669' • r :00 -3 2 - ,
Issued by: " e 4. ./V;) Permittee Signatur =. 1
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 complet'on of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # 1512600- 00300: ' -
Tenant Name: Kay Jewelers This SWR# 2005 - 00270 , •
Site Address: 9312 SW Washington Sq. Rd This PLM# 2005 - 00329 • - • _ -_ ;
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 ,.�,u; - . - 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 - 1 , 5 1 5
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 6 0 0 - ,, r 0 0 0
Garbage Disposal •
- Domestic (to 3/4 HP) 16 , ' _ _ . -� 0 .w ' 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 42 0 4.-: :1-, , 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 , .' ''`- , 0Y::, 0 1 2 1 2
- Bradley 5 0 ~ 0 0 0 0
- Commercial 3 0„,, 0 1 3 1 3
- Service 3 0 ?_- 0 0 0 0
Swimming Pool Filter 1 0.r -u 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 6 1 6
Urinal 6 .- 0 0 0 0 0
Previous EDU Count " 0 0
Capped EDU Credit : , ,'': 0
TOTALS 0 0 0 0 4 16 4 16
Current Fixture Value 16 divided by 16 = 1.0 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 16 divided by 16 = 1.0 over (under) $ 2,600.00
Enter EDU Change Here , ,,1
Notes:
Authorized Name /Signature: Dodie Rossetti Date: ' 8/31/2005 ' . 9/Z/Q`f16
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\Sewer Tally \SewerTallySheet.xls 7/1/05