Permit CITY OF TIGARD SEWER CONNECTION PERMIT
s `Y S , COMMUNITY DEVELOPMENT Permit #: SWR2011 00174
TIGARD, 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/21/2011
Parcel: 1 S136CD00100
Jurisdiction: Tigard
Site address: 11705 SW PACIFIC HWY M
Project: Sushi Hanna Subdivision: 2006 -016 PARTITION PLAT Lot: 3
Project Description: .8 EDU increase
Contractor: Owner: PACIFIC CROSSROADS PROPERTIES IN
BY WYSE INVESTMENT SERVICES CO
1501 SW TAYLOR ST STE 100
PORTLAND, OR 97205
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 12/21/2011 $3,600.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .8
Total $3,600.00
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable
law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if
work is susp more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. ose rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUN by calling 503.232. 8 or 1.80 2.2344.
Issue By: � � p Permittee Signature. r j � / -s�l
Call 503.639.4175 by 7:00 a.m. for the next available insp— " • n date.
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.
Tenant Name: Sushi M Accumulative Sewer Tally
Manna Accumulative
# 2011 -00174
1 2 '," Site Address: 11705 SW Pacific Hwy Suite M PLM # 2011 -00378
Parcel #: 1S136CD00100
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total 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 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:
- Lav /Bar - Non -Food Related 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Com /Sery /Util - Food Related 3 0 0 4 12 4 12
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 4 _ 12 4 12
Current Fixture Value 12 divided by 16 = 0.8 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 12 divided by 16 = 0.8 over (under) $ 3,600.00
Enter EDU Change Here 0.8
Notes:
Authorized Name /Signature: Debbie Adamski (cal- Date: 12/21/2011
Building Division
ote: 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- 4500.xls 07/01/11