Permit CITY TIGARD SEWER CONNECTION PERMIT
A toveiN DEVELOPMENT SERVICES PERMIT #: SWR2004 -00151
— 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/25/2004
SITE ADDRESS; 12909 SW 68TH PKWY 400 PARCEL: 2S101AD -03200
SUBDIVISION: TIGARD OFFICE BUILDING ZONING: MUE
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: MORTGAGE DESIGN GROUP
USA NO: FIXTURE UNITS: 3
CLASS OF WORK: ADD DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .2 EDU increase
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [SWUSA] Swr Connecti( 5/25/2004 $480.00
[SWUSA] Swr Connecti( 5/25/2004 $0.00
Phone: Total $480.00
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"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Oreg i i y 'fication Center. Those rules are set forth in OAR 952 -001 -0010 through O • ' 952 -001 -0100. You
ma obtain copies • these rules or direct questions to OUNC by calling (503) 246 -6699.
Is ed by: Permittee Signature
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the At business day
Accumulative Sewer Tally Parcel # f2S1g111A15SQ32b0 ' .� h
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"Site Addre 12909:SW'68th `Pkwy #400, - , This PLM #;20,04x0;0232„ <f M, .; i' a ;xN
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 _';. r; x., ; 0 ;:4, '; %,,3,..,,- 0 . *. y : ` 0 0 0
Bath - Tub /Shower 4 G „,'''..:::',,.A;,.: 0 c ;)„ r °N : =, <;, 0 0 0 0
- Jacuzzi/Whirlpool 4 n, 0 �rl 0 g;:° 0 0 0
Car Wash - Each Stall 6 ` . -„ ; 0 ; ; ` .. 0 0 0 0
- Drive through 16 , r 0 ,, ; ' ` ; 0 , 0 0 0
Cuspidor/Water Aspirator 1 x ,: - 0 ,w 1, 0 '< 0 0 0
Dishwasher - Commercial 4 r , ; ? °.: 0;' 0 x : f.`. $ aii 0 0 0
- Domestic 2 Matti 0 '';`14iitaS 0 iorot 0 0 0
r-:2 �_ #” x ;: %'' `,' .. ,1,
Drinking Fountain 1 �; E F 0 : „ :; ;: 0. 0 y s ; 0 0 0
Eye Wash 1 `? . 0 ' " 0 r r;
Floor Drain /Sink - 2 inch 2 F` x r ;: 0 0 _z; r 0 0 0
3 inch 5 sN .;; 0 r: 0 , °'y`r;. 0 0 0
-flinch 6 3ry 0 ? „, s 0 P .< 0 0 0
- Car Wash Drr 6 * ': xi`: `,-� 0 0 ,WAS IV 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 >3A14. 0 `" ` '4 0 i � ^ ` 0 0 0
- Commercial (to 5 HP) 32 WON 0 r' 0 } 0,S. 0 0 0
Industrial (over 5 HP) 48 ; ' . 4 0 ` W 0 , :> '
Ice Machine /Refrigerator Drain 1A';I 0 ;V "VA 0 0 0
Oil Sep (Gas Station) 6 ,.. T : 0 0 * 1 0 0 0
Rec. Vehicle Dump station 16 0•: 0 ; 0 MIA 0 0 0
Shower - Gang (per head) 1 - 0 R 0 Mit0V 0 0 0
Stall 2 `'& 0 ifiglig 0 0 0 0
Sink - Bar /Lavatory 2 s; 0 ' z rte:
.laadr'.4 ;k
- Bradley 5 �,'.:` > ;� , 0 'M'`y �,` r 0 '' `f':.: :' 0 0 0
- Commercial 3 ,; P b, g 0 , A 0 ' 0 0 0
- Service 3 M'n 0 W;:; 0 .. go 3 1 3
Swimming Pool Filter 1 ;' 'A- f 1, 0 UM 0 , ' ` 0 0 0
Washer - Clothes 6 r esx 0 .a,. 0 !AIM 0 0 0
Water Extractor 6 i ;r; fig: 0 :.'0442 N`z 0 d . a; 0 0 0
Water Closet - Toilet 6 .� ', , 0 k ; ; . 4 4 i'r -'s^� 0 0 0 0
Urinal 6 rit',:ft. 0 svita 0 ri;,:n,'`A 0 0 0
Previous EDU Count €" 0 0
Capped EDU Credit ?,i u,i 0
TOTALS 0 0 0 0 1 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) $ 480.00
Enter EDU Change Here "i, fO-2
Notes:
Si ature: C Date: 5 le?
Building Division
lw Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
hich 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