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Permit CITY OF TIGARD ' '' `' : - .) SEWER CONNECTION PERMIT COMMUNITY DEVELOPMENT L Permit #: SWR2011 -00128 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 09/07/2011 Parcel: 2S101AB00100 Jurisdiction: TIGARD Site address: 12005 SW 70TH AVE Project: Acupuncture Clinic Subdivision: Lot: Project Description: 2.4 EDU's for first tenant. Initial sewer tap for new building. Contractor: Owner: RED ROCK BUSINESS ASSOCIATES LLC 23077 SW NEWLAND RD WILSONVILLE, OR 97070 PHONE: PHONE: FAX: FEES Description Date Amount Specifics: Sewer Connection Fee 09/07/2011 $10,800.00 Sewer Inspection - Commercial 09/07/2011 $45.00 Type of Use: COM Class of Work: ALT Install Type: Line Tap and Building Sewer Fixture Units: Number of Dwelling Units: 2.4 Total $10,845.00 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: Call 503.639.4175 by 7:00 a.m. for the next available inspection date. 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 Tenant Name: Mup,untiire Clink. ' •c.• • „ ,... • .''. . - .1 - ' :,.. 4.• SWR # ■2011L00128.i .•, • . • ••••. „ . .-- ' • . -n-li,.. Site Address: :120.05;sW„.70:hr ..,,4. .. • t.,,., ...7• ...•-:, :L..; ....,.. .. „ .,' ' .. ' .4 •, PLivi # 2011 002 : ,:.:' .• • '.': Parcel #: , • .:::C.: :',:- Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped #s value count added # added value total #s total values - Baptisery/Font 4 4:Mi 0 0 '..1, '.tSt 0 0 0 Bath: - Tub/Shower 4 !t .I,, 1 0 h12#1.12. 0 i.:: ,. . '. Va.,* -.IP 1.-.1. 0 0 0 - Jacuzzi/Whirlpool 4 PRig. 0 E.7!;-.%. 0 i :, ; - - .A-.: 0 0 0 Car Wash Each Stall 6 0 .. t.,.. i;:i. ii!' • ; niir ; : - 1i--,..:•-t •,,., • -- .1 . .., , . ..... 0 4..4....•- - '• • : ' k 0 0 0 • ,- - Drive through 16 . . F . 0 0 V , ••,. _--'. : . 0 0 0 - - •' '.• Cuspidor/Water Aspirator 1 • - ii 0 0 ,, - ..-- • .r.- 0 0 0 Dishwasher: - Commercial 4 - •-•- ..4 • - :•• 0 :,.;,•• • y S.' ..1' . ."•r ? 0 14 - '.' ' ' '.i..' ,!... \.- 0 0 0 Domestic 2 .-..:7;:, 0 • - IT • p 0 r ... v ....r.. . 0 0 0 . , . . Drinking Fountain 1 .1 . , 0 0 ' 0 0 0 . .. • Eye Wash I 0 0 '.... k.:1 0 0 0 - • .. • ,• , Floor Drain/Sink: -2 inch 2 - ., -• 0 0 . ..."‘r. '..1 • ', 2 1 2 , .. ':5'•••.4,.'-::••:p. • ., - 3 inch 5 A - :,: .- j ''''• ; 0 0 IC:: 7- - .. 0 . 0 0 . tg .- • • - 4 inch 6 ''... ,.. f '.1 0 . .. ' •.....':..11. 0 0 0 0 - Car Wash 6 . .. .• ' . • t ...e. 0 _-'-, .• '1 VS 0 :1:. „'.1r, 0 0 0 Garbage Disposal: -• , „ . , •_-t--- ,...„. - Domestic (to 3/4 1-EP) 16 ' ■ •.J • 0 0 0 0 0 - Commercial (to 5 HP) 32 .. .....' 0 0 0 0 0 •..,. - • . . - Industrial (over 5 HP) 42 •• ''.•• 0 *?, • . - - . • • 0 :. l ' • , . 0 0 0 .. Ice Machine/Refrigerator Drain 1 ' I 4--F t• '• . • . _.. . 0 0 . .. _ 0 0 0 . . Oil Sep (Gas Station) 0 0 , .• . --, . 0 0 0 Rec. Vehicle Dump station 16 . ' ••••• - ,. . 0 , , , . ,,. ... ,...,. 0 . , ti'-'.: r 0 0 0 - .-• , • " Shower: - Gang (per head) 1 - • 0 0 %.". ' % 0 0 0 . '‘ .. - -',- •, : _ I. _ • - - Stall 2 ,' •. .- 1 0 0 2 1 2 Sink: - Lay/Bar - Non-Food Related '• 0 4,' 0 10 5 10 - Bradley 5 r,-.... '..-:',:-.12:1 0 -.."`.-'-.11: ll'irtilk-..1'.. `:•;• 0 , . 0 0 0 Com/Serv/Util - Food Related 3 t'21 • :•;-;t1 0 , k, ••• e' 0 . • - _ 0 0 0 Swimming Pool Filter 1 r. ; 0 0 • " • •- • •• 0 0 0 Washer - Clothes 6 -.•'.......•:_ 0 :..,r,e:ii.3•;--1 0 :: -,,i447 6 1 6 1.«•,:4-ri,,•- , ater Extractor 6 . . • . W 3 ... -..... -.. . 0 ;,?■12,•,,9. 1 • .....;:, 0 -. • .. ... ... - . . 0 0 0 Water Closet-Toilet 0 't" : 41:: '4' , 0 . 1 ... -': 18 3 18 .• •.." • - • ,. ■ ---., '. , i Urinal 6 0 • -iV 0 •. -17 • .'4%. 0 0 0 Previous EDU Count 2„;„,,,11..4, -4 0 0 Capped LOU Credit --?-•• 1 .- ..., 0 TOTALS 0 0 0 _ 0 _ 11 _ 38 11 _ 38 Current Fixture Value 38 divided by 16 = 2.4 Current EDU 1 EDU = $4,500.00 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 38 divided by 16 = 2.4 over (under) $ 10,800.00 Enter EDU Change Here: 2.4: Notes: No demo credits at this time. Authorized Name/Signature: balbrei'Xdahia'd ..-: ... 4 - : ..: • .. - .. • Date: , - -..6/...i5J2o1.1 .,. , ' • . '.. ' ''. • . , _- Building Division Note : The property owner.shall•retain the'ORIQINAL..sewet tally record. If credits exist, this document will serve as a voucher which must be ' subrnitted.to the City of 'riga' 9:1 Building Division to future system development charges. , 1: \ Building\ Sewer Tally \ SewerTallySheet-4500.xls 07/01 /11 1 - Accumulative Sewer Tally 4 " Tenant Name: Acupunture Clinic SWR # 2011 -00128 Site Address: 12005 SW 70th Ave PI.M # 2011 -00273 F1GwR17 Parcel #: 2S101AB 00100 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped #s value count added # added value total #s total values Baptistry/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 6 0 0 0 0 0 Garbage Disposal: - Domestic (to 3/4 I IP) 16 0 0 0 0 0 - Commercial (to 5 11P) 32 0 0 0 0 0 - Industrial (over 5 I IP) 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 1 2 1 2 Sink: - Lay/Bar - Non -Food Related 2 0 0 8 16 8 16 - Bradley 5 0 0 0 0 0 - Com /Serv/Util - Food Related 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer - Clothes 6 0 0 1 6 1 6 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet 6 0 0 3 18 3 18 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 0 '10'l'AI.S 0 0 0 0 14 44 _ 14 44 Current Fixture Value 44 divided by 16 = 2.8 Current EDU 1 EDU = $4,500.00 Previous Fixture Value 0 divided by 16 = 0.0 Previous I?DU Change 44 divided by 16 = 2.8 over (under) S 12,600.00 Enter EDU Change Here 2.8 Notes: No demo credits at this time. 4/11/12: Added (3) non -food related sinks to PI ,M2011-00359 for Wolcott Plumbing; quantity changed from (5) to (8) non -food related sinks. PI,M2011 -00359 is a continuation of P1.M2011- 00273. I ?DU's changed from 2.4 to 2.8 -- difference of 51,800.00. Authorized Name /Signature: Debbie Adamski / Branden Taggart (4/11/12) Date: 8/25/2011 , 4/11/2012 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 \Sewerl'allySheet- 4500.xls 07/01/11