Permit CITY TIGARD SEWER CONNECTION PERMIT
� 1 � DEVELOPMENT SERVICES PERMIT #: SWR2005 -00140
I- ' 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 4/22/2005
PARCEL: 25101 DC -00200
SITE ADDRESS; 13535 SW 72ND AVE 150 ZONING: C -
SUBDIVISION: 72ND AVE OFFICE BUILDING LOT: JURISDICTION: TIG
Project Description: .2 EDU increase.
TENANT NAME: CREDIT UNION HOME LOAN
CWS NO: FIXTURE UNITS: 3
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
PACIFIC NW PROPERTIES LTD PTNSHP
9665 SW ALLEN BLVD STE 115 Description Date Amount
BEAVERTON, OR 97005 [SWUSA] Swr Connection Fee 4/22/2005 $500.00
Total $500.00
Phone: 503 626 - 3500
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
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
Oregon Utility Notification Center. Those rules are set forth in OAR 952 =001 -0010 through OAR 952 - 001 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued by: Permittee Signature: �Q,�/
Call 503 -639 -4175 by 7:00 a.m. for an inspection that business day.
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 Parcel # 2S101DC -00200 ,
Tenant Name: Credit Union Home Loan This SWR# 2005 -00140 '
Site Address: 13535 SW 72nd Ste. 150 This PLM# 2005 -00153
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 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 Drr 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
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 - Bar/Lavatory 2 0 0 0 0 0
- Bradley 5 ,. • 0 0 •;, 0 0 0
- Commercial 3 0 0 1 3 1 3
- Service 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 1 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) $ 500.00
Enter EDU Change Here 0.2
Notes: '7
Signature: / -i�Z k41eLL ,. 4177/41. Date: 4/ /h._ t f �; t
Building Division / /
(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 7/1/04