Permit •'
C ITY OF TIGARD SEWER CONNECTION PERMIT
�A DEVELOPMENT SERVICES
PERMIT #: SWR2005 -00062
�� I 13125 SW Hall Blvd, Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/1/2005
SITE ADDRESS; 098 SW WZSI- INGTON SQUARE RD F -2 PARCEL: 1S12600 -00300
SUBDIVISION: WASHINGTON SQUARE ZONING: C -
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: CRABTREE & EVELYN
CWS NO: FIXTURE UNITS: 3
CLASS OF WORK: ADD DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .2 EDU increase
Owner: FEES
WASHINGTON SQUARE LLC Description Date Amount
BY THE MACERICH COMPANY
9585 SW WASHINGTON SQUARE RD [SWUSA] Swr Connection Fee 3/1/2005 $500.00
TIGARD, OR 97223
Total $500.00
Phone:
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 Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 -001 -0100. You
may ob ..• - - of these rules or direct questions to OUNC by calling (503) 246-6699.
•
�I , n/
Iss ed by: L � � �,� _�- _ Permittee Sig �Ci� y
Call (503) 639 -4175 by 7:00 P.M. for an inspection the next 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 # AS12600200300 < , , ,
Tenant Name: Crabtree & Evelyri ' . ' -' , ' This SW RA 2005 -00062
Site Address: -968 SW',Washington Square Rd This PLM# 2005 -00071 - .
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 • ' . -' k 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) 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 ° ` , `„i„, . 0 0 0 0
- Stall 2 , : ' 0 0 , ;,,,V,-, , 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 - y _ 0 0 0 0
- Commercial 3 0 0 . `'1. -. "!, 3 1 3
- Service 3 - 0 0 0 0 0
Swimming Pool Filter 1 0 0 - ;1 0 0 0
Washer - Clothes 6 0 '' , 0 0 0 0
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Water Extractor 6 0 0 :;.'s',1- 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 = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) $ 500.00
Enter EDU Change Here _ , 0.2
Notes:
Sig ature: .. i i $ , / ,P Date: o
Building Division
(Note 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 7/1/04