Permit •
CITY TIGARD SEWER CONNECTION PERMIT
( i 4 DEVELOPMENT SERVICES PERMIT #: SWR2004 -00200
l 13125 SW Hall Blvd., Tigard, OR 97223 (503 ) 639 -4171 DATE ISSUED: 7/15/2004
SITE ADDRESS; 10260 SW GREENBURG RD 386 31 PARCEL: 1S135AB-03400
SUBDIVISION: LINCOLN TOWER - TOWN OF METZGER ZONING: C - P
BLOCK: LOT: 014 JURISDICTION: TIG
TENANT NAME: MASTER CARE
USA NO: FIXTURE UNITS: 2
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: IMPERV SURFACE:
Remarks: .1 EDU increase.
Owner: FEES
EQUITY OFFICE PROPERTIES TRUST Description Date Amount
10260 SW GREENBURG RD #100
TIGARD, OR 97223 [SWUSA] Swr Connectic 7/15/2004 $250.00
[SWUSA] Swr Connectic 7/15/2004 $0.00
Phone: 892 - 2500
Total $250.00
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
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) 246-66 .
&C--?
awe Issued by: � Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally Parcel # 1S135AB- 00900''
Tenant Name. MaS1er "Care This SWR #2004 -00200
Site Address:, -1Q2 0 W Greenburg Ste. #3$6, This PLM# ,2004- 00319 .
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 Mil 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 ,' 1 2 1 2
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 h s 0 0 0
Garbage Disposal __ - --
- Domestic (to 3/4 HP) 16 ;: 0 q -` 1" '
- Commercial (to 5 HP) 32 0 1 0 0 0 0
- Industrial (over 5 HP) 48 0 ' 3 i 0 0 0 0
Ice Machine /Refrigerator Drain 1 MI 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 IIIIIII 0 ::;:.: 0 0 0
Stall 2 0 0 ,': 0 0 0
Sink - Bar /Lavatory 2 ;i :ai'''', ` 0 ® 0 0 0 0
- Bradley 5 0 11111.11 0 Aid ., 0 0 0
- Commercial 3 .. 0 0 .4' 0 0 0
Service 3 .. 0., , 0 0 0 0
Swimming Pool Filter 1 0 ` ` .
Washer - Clothes 6 :,,, 0 ' �f, H 0 0 0 0
Water Extractor 6 f }A. r: 0 0 s 0 0 0
Water Closet - Toilet 6 , 0 0 ;; ;, 0 0 0
Urinal
6 0 .. 0 a mx
0 0 0
Previous EDU Countl 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 1 2 1 2
Current Fixture Value 2 divided by 16 = 0.1 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) $ 250.00
Enter EDU Change Here O/ _
Notes:
Name: Id ,,,,...„,,.z. �` - / Date: 7// V
Building Division
Note: The property owner shall retain this record for sewer credit purposes. In the event of a credit, this
document stamped "ORIGINAL" shall serve as a credit voucher and must be submitted to the City of
Tigard Building Division to redeem credit towards future system development charges.