Permit (2) CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2020-00011
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/13/2020
TIGARD 9 Parcel: 2S101 AC01300
Jurisdiction: Tigard
Site address: 7105 SW HAMPTON ST
Project: Kaiser Dental Subdivision: BEVELAND NO.2 Lot: 18-19, P
Project Description: .13 EDU increase.
Contractor: Owner: KAISER FOUNDATION HEALTH
PLAN OF THE NORTHWEST#838
ATTN PROPERTY ACCOUNTING
500 NE MULTNOMAH ST
PORTLAND, OR 97232
PHONE:
PHONE: 503-348-6291
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 01/13/2020 $754.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .13
Total $754.00
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 87 0 1.800. 3 .2344.
Issued By: / Permittee Signature: --��
Call 503.639.4175 by 7:00 a.m.for the next available inspection ate.
This permit card shall be kept in a conspicuous place on the job site until comp ' o roject
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally
III i Tenant Name: KAISER DENTAL SWR# 2020-00011
Site Address: 7105 SW HAMPTON ST PLM# 2020-00006
TIGARD
Parcel#: 2S 101 AC01300
Fixture Value Previous Previous Credits Capped Fixture Fixture New Ncw
# 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 IIP) 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
riving 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 1 2 2 4 1 2
-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 1 2 2 4 1 2
Current Fixture Value 2 divided by 16= 0.125 Current EDU 1 EDU= $5,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous liDU
Change 2 divided by 16= 0.125 over (under) $ 754.00
Enter EDU Change Here 0.130
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 1/6/2020
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:A Building\Sewer Tally\SewerTallySheet_5SW_070119.xisx