Permit C ITY OF TIGARD SEWER CONNECTION PERMIT
� ;� DEVELOPMENT SERVICES PERMIT #: SWR2005 -00164
Ail, -' 13125 SW H all Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 5/26/2005
PARCEL: 2S 101 AB -01606
SITE ADDRESS; 07357 SW BEVELAND RD 100 ZONING: MUE
SUBDIVISION: HERMOSO PARK LOT: 017 JURISDICTION: TIG
Project Description: 1 EDU increase.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
TOM CLARKE
12448 SW ORCHARD HILL RD Description Date Amount
LAKE OSWEGO, OR 97035 [SWUSA] Swr Connection Fee 5/26/2005 $2,500.00
Total $2,500.00
Phone: 503- 293 -1226
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 - 0019- through OAR 95kb01 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling 503-246-6699 Or 1400 -332 -2344.
/
Issued by: .. C \---&i Permittee Signature
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 # 2D101SB - 01606
Tenant Name: Beveland St. Coffee House This SWR #'_2005 -00164
Site Address: 07357 SW Beveland, Ste. 100 This PLM# 2005 -00215
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 1 4 1 4
- 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 1 2 1 2
- 3inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 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 1 1 1 1
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 3 9 3 9
- 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 6 16 6 16
Current Fixture Value 16 divided by 16 = 1.0 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 16 divided by 16 = 1.0 over (under) $ 2,500.00
Enter EDU Change Here
...........
Notes:
Signature: • DC -. 1,---,,. c - L-- D-,: -, G -.. Date: 6/0 [-/ T ---,
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 7/1/04