Permit CITY TIGARD SEWER CONNECTION PERMIT
A � DEVELOPMENT SERVICES PERMIT #: SWR2005 -00277
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 9/22/2005
PARCEL: 1S12600-00300
SITE ADDRESS: 09360 SW WASHINGTON SQUARE RD ZONING: C -
SUBDIVISION: WASHINGTON SQUARE LOT: JURISDICTION: TIG
Project Description: 1.7 EDU increase
TENANT NAME: GODIVA CHOCOLATIER
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ADD DWELLING UNITS: 1.7
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 9/22/2005 $4,420.00
TIGARD, OR 97223
Total $4,420.00
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 follow rules adopted by the
Oregon Utilty otification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You
may in copies o e - I or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Is ued by: 1
/ _J/(_I_ Permittee Signature: ar�
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 # 1S12600= 00300 .
Tenant Nari'e:'Gotiva Chocolatier This SWR #2005 -00277
Site Address: 9360 SW Washington Sq Rd This PLM# 2005 -00408 '
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 ' 2 10 2 10
- 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) 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 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 3, 9 3 9
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 7 27 7 27
Current Fixture Value 27 divided by 16 = 1.7 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 27 divided by 16 = 1.7 over (under) $ 4,420.00
Enter EDU Change Here 1.7 ,
Notes:
Authorized Name /Signature: Debbie Ad -mski A _ � Date: 9/6/2005
ildiision
(■ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
hich 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