Permit CITY OF TIGARD SEWER CONNECTION PERMIT
- COMMUNITY DEVELOPMENT Permit#: SWR2014-00130
T[CARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/30/2014
Parcel: 2S 101 AA08700
Jurisdiction: Tigard
Site address: 12511 SW 68TH AVE
Project: Kassay Clinic Subdivision: WEST PORTLAND HEIGHTS Lot: 34
Project Description: .5 EDU increase.
Contractor: Owner: BEVELAND BUILDING LLC
12511 SW 68TH AVE
PORTLAND,OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 12/30/2014 $2,450.00
Type of Use: COM
Class of Work: ALT
Install Type:
Fixture Units:
Number of Dwelling Units: .5
Total $2.450.00
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-tfie Oregon Utility Notification
Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a c■% of jhe rules or direct questions
to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
Call 50 ..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 pr.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally
14' Tenant Name: KASSAY CLINIC SWR# 2014-00130
Site Address: 12511 SW 68TH AVE PLM# 2014-00406
I �'A Parcel#: 2S 101 AA08700
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 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 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 0
Living Unit 16 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:
-Lav/Bar-Non-Food Related 2 0 0 4 8 4 8
-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 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 8 4 8
Current Fixture Value 8 divided by 16= U500 Current EDU 1 EDU= $4,900.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 8 divided by 16= 0.500 over (under) $ 2,450.00
Enter EDU Change Here 0.500
Notes:
Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 12/29/2014
Building Division
ote: The property owner shall retain the ORIGINAL sewer tally record. If 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.
1:\Building\Sewer T ally\SewerTallySheet_49(N)._070114.xlsx