Permit CITY OF TIGARD
SEWER CONNECTION PERMIT
�i� DEVELOPMENT SERVICES PERMIT #: SWR2004 -00118
�' I I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/19/04
SITE ADDRESS; 10246 SW WASHINGTON SQUARE RD PARCEL: 1S135BA -00102
SUBDIVISION: O4II1BURG ZONING: C -G
BLOCK: LOT: 001 JURISDICTION: TIG
TENANT NAME: BRAVA HASSLE FREE MEALS
USA NO: FIXTURE UNITS: 10
CLASS OF WORK: ADD DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .6 EDU increase
Owner: FEES
BY THE MACERICH COMPANY Description Date Amount
9585 SW WASHINGTON SQUARE RD
TIGARD, OR 97223 [SWUSA] Swr Connect 4/19/04 $1,440.00
[SWUSA] Swr Connect 4/19/04 $0.00
Phone:
Total $1,440.00
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" Perm
A A O
I ued by: ' ' :Or Permittee Si nature: 4i� / /
Call (503) 63' 4 175 by 7:00 P.M. for an inspection need: . th- ext business day
Accumulative Sewer Tally Parcel # 1S133AD-02200
Tenant - Name: Brava Hassle Free Meals This SWR# 2004 -00118
Site Address: 10246 SW Washington Square Rd This PLM# 2004 -00159
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 1 2 1 2
- 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) 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 0 1 2 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 2 6 2 6
- 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 4 10 4 10
Current Fixture Value 10 divided by 16 = 0.6 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 10 divided by 16 = 0.6 over (under) $ 1,440.00
Enter EDU Change Here 0.6
Notes: ■
_
I .1,
gnature: 111=11. Date: 'J► /'
' .. ing Division
Note: The propert caner 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 11/19/03