Permit CITY OF TIGARD SEWER CONNECTION PERMIT
11- 4_ COMMUNITY DEVELOPMENT Permit#: SWR2013 00176
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/08/2013
Parcel: 2S 101 AD00800
Jurisdiction: Tigard
Site address: 12550 SW 68TH AVE
Project: Heintzberger/Payne Subdivision: WEST PORTLAND HEIGHTS Lot: 26
Project Description: .38 EDU increase
Contractor: Owner: BHKZ LLC
12600 SW 68TH PKWY
PORTLAND, OR 97223
PHONE: PHONE: 503-546-4151
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 08/08/2013 $1,824.00
Type of Use: COM
Class of Work: ALT •
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .38
Total $1,824.00
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 cosy of the rules or direct questions
to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued `I, Permittee Signature: atigh■:ill
�r.
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.
1111 •a
Accumulative Sewer Tally
p 'Tenant Name: l-Ieintzberger Payne "REVISED TO CORRECT PERMIT_NUNIBI•.RS" SWR# 2013-00176
Site Address: 12550 SW 68th Ave PI.N1 # 2013-00272
TIGARD•
Parcel#: 2S101AD00800
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#5 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
14e 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 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 I-IP) 16 0 0 - 0 0 0
-Commercial(to 5 1-IP) 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 2 4 2 4
Sink:
-l,av/Bar-Non-Food Related 2 0 1 2 2 4 1 2
-Bradley 5 0 0 0 0 0
-Cum/Sery/Util- Food Related 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 [DU Count 0 0
Capped EDU Credit 0
'I'O'1',U.S 0 0 1 2 4 8 3 6
Current Fixture Value 6 divided by 16= 0.375 Current IiDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 6 divided by 16= 0.375 over (under) S 1,824.00
Enter EDU Change Here 0.380
Notes:
Authorized Name/Signature. Debbie Adamski Date: 8/8/2013
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\Sewer TallyShect_4800._07UI 13.xlsx
Accumulative Sewer Tally
0
11114 C Tenant Name: 1 leinrzberger Payne S\VR# 2013-00272
TI GA 11[:) Site Address: 12550 SW 68th Ave PI.NI # 2013-00176
Parcel#: 2S101AD00800
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptiser?/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 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 HP) 16 0 0 0 0 0
-Commercial(to 5 HP) 32 0 0 0 0 0
-Industrial (over 5 1-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 2 4 2 4
Sink:
-Lav/Bar-Non-Food Related 2 0 1 2 2 4 1 2
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 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
'I'O'1':U,S 0 0 1 2 4 _ 8 3 6
Current Fixture Value 6 divided by 16= 0.375 Current •.DU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 6 divided by 16= 0.375 over (under) S 1,824.00
Enter EDU Change Here' 0.380
Notes:
Authorized Name/Signature:,Debbie Adamski Date:' 8/8/2013
Building Division
ote: The property owner shall retain the ORIGINAL sewer tally record. I f credits exist,this document will serve as a voucher which must be
ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
:\Building\Sc„vcr'!'ally\Sewer l'allyShect_48U 111._1171 it 13.xlss