Permit CITY T I GA R D SEWER CONNECTION PERMIT
i DEVELOPMENT SERVICES
PERMIT #: SWR2006 -10016
`''�' �i 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 - 4171 DATE ISSUED: 6/28/2006
PARCEL: 2S1 13AD -01700
SITE ADDRESS: 16940 SW 72ND AVE ZONING: C -G
• SUBDIVISION: ROSEWOOD ACRE TRACTS LOT: 030 JURISDICTION: TIG
Project Description: 2.1 edu increase.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ADD DWELLING UNITS: 2.1
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
BRIDGEPORT LAND LLC
3939 NW ST HELENS RD Description Date Amount
PORTLAND, OR 97210
[SWUSA] Sewer Connection Fee 6/28/2006 $5,460.00
Phone: 503 241 - 2875
Total $5,460.00
Contractor:
REQUIRED ITEMS AND REPORTS
Contact #:
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. Thos
. 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 :fling 503 - 246 -6699 or 1- 800 - 332 -2344.
IP 41111 .,
Issued by: !. - Permittee Signature:
1
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 projec
Approved plans are required on the job site at the time of each inspection.
.Accumulative Sewer Tally — # x2S113AD 01700 ,,. ..,...•
Tenant Name M War s "s.> 1< : ? „, :,_:t”. ', This SWR# 200,6,1OO16
Site Address 169401SW 72nd Ave s la This PLM #2006OOQ77x , , ,Ek.v ,. ,,;
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 :1071.!.30 0 ',F 0 0 0 0
k; • Bath - Tub /Shower 4 wi k, ,. 0 ,; 0 . ' , „ 0 0 0
f' ,-
- Jacuzzi/Whirlpool 4 N � ,g,,,� 0 w , , ,i:. 0 0 0 0
Car Wash - Each Stall 6 m t s' 0 ;r 0 0 0 0
- Drive through 16 0 n 0 0 0 0
Cuspidor/Water Aspirator 1 .nr....f; 0 x , 0 G ` 0 0 0
Dishwasher - Commercial 4 > S , ` 0 0 3 ., . 0 0 0
- Domestic 2 Val, 0 0 0 0 0
n
Drinking Fountain 1 ,.U=.: , r 0 y , 6 £ 0 e ,,. ; 0 0 0
Eye Wash 1 01,71111 0 Ellalili 0 1E2E. 0 • 0 0
Floor Drain /Sink - 2 inch 2 1,0 0 ,..,.' 0 ME, 0 0 0
- 3 inch 5 ,,, n 0 WWI 0 Ham 3,,` 15 3 15
0 n*. , 0 ice, . ,
0 0 0
- 4 inch 6.i
- Car Wash Drr 6 .1 0 3 x , 0 1111131 31 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 MI. 0 : 4111411 0 F 0 0 0
- Commercial (to 5 HP) 32 a!,,.. 0 w u �, I 4 ., _, ; 0 IM
- Industrial (over 5 HP) 42 i, 1. 0 i, "M 0 t, 0 0 0
0 0 0
non: Machine/Refrigerator Drain 1 n�y_ 0
. n„ 0 m . *.'
Oil Sep (Gas Station) 6 ' T ,„ 0 g.x . 0 5, 0 0 0
Rec. Vehicle Dump station 16 � lg, 0 , „ A 0
k _ ,F -A 0 0 0
Shower - Gang (per head) 1 ryz 0 l ' ' 0 q , A 0 0 0
0 .g: :
- Stall 2 „ A 0 x..lx ` 0 0 0
Sink - Bar /Lavatory 2 .�, . � >.k � 0 x 0 r 5* � 4 2 4
�k _�
- Bradley 5 ;' 0 a.Z 0 0, 0 0 0
Commercial 3 § 0 gialla 0 PaRgi4 3 1 3
F x
- Service 3 f s:v.0 0 :� 0 x _5 < 0 0 0
Swimming Pool Filter 1 ga gar 0 IMENS IM;; 0,,, '; 0 0 0
Washer - Clothes 6 - , . 0 ,,,.,, . , >; 0
Water Extractor 6 ViFt. 0 0 i _ 0 0 0
Water Closet - Toilet 6 lail` ' 0 EINE 0 Illigill 12 2 12
s.S
Urinal 6 . 3: 0 0441 > >, 0 iglitSda 0 • 0 0
Previous EDU Count . 0 0
a
Capped EDU Credit - :,3 0
TOTALS 0 0 0 0 8 34 8 34
Current Fixture Value 34 divided by 16 = 2.1 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 34 divided by 16 = 2.1 over (under) $ 5,460.00
Enter EDU Change Here 21
Notes:
Authorized Name /Signatu.e: : ' �A/.,.•, l - - r Date:. • 3/2 „ '
. 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 \SewerTallySheet.xls 7/1/05