Permit CITY OF TIGARD
SEWER CONNECTION PERMIT
Pfr DE VELOPMENT SERVICES PERMIT #: SWR2005 -00263
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 9/1/2005
PARCEL: 2S103DD -00800
SITE ADDRESS: 13815 SW PACIFIC HWY 110 ZONING: C -
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: .5 EDU increase.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.5
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
D.W. SIVERS COMPANY
4730 SW MACADAM AVE Description Date Amount
#101 [SWUSA] Sewer Connection Fee 9/1/2005 $1,300.00
PORTLAND„ OR 97201
Total $1,300.00
Phone:
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 folio . - adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -1110 throug GAR 152- 001 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling .1 -246 .699 or 1 -81.'4 ' -2344.
Issued by: Permittee Signa I - . �� ,
Y 451.41o741 , -
Call 503 - 639 -4175 by 7:00 a.m. for an inspe ' ion t -at business day.
This permit card shall be kept in a conspicuous place on t e jo site until completion of the project.
Approved plans are required on the job site at e time of each inspection.
Accumulative Sewer Tally Parcel # 254041`,0Ig, , x ';,,,,',
Te>lant Na" ne: Gar1ic44i0s Piz ' This SW R# 2, ?b5 615:10, h '_
Site Address: 13815 SW P.aeafic H-Ste #110 ' , This PLM# 201 Q4 .. ,, . » a t, ,.;:
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 te r:; ,, 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 ,, ,, , 0 0 0
- Domestic 2 ;„ 0 gi.., 0 A.g2 „ 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 ,, ..,x 0 0 0 0
Floor Drain /Sink - 2 inch 2 •T,. 0 r L r 0 ,;: 2 1 2
3 inch 5 `' $ ,
- 4 inch 6 ,� 0 = ;;F ' ': 0 Law, 0 0 0
- Car Wash Drn 6 . . max
0 .. _ 0 � a `> 0 0 0
Garbage Disposal
Domestic (to 3/4 HP) 16 >`, ` x' 0 gel 0 *, i N: 0 0 0
- Commercial (to 5 HP) 32 V 0 v 0 .0. r ` 0 0 0
� r ; � of
- Industrial (over 5 HP) 42 0 Y , ; 0 ;� 4 , 0 0 0
Ice Machine /Refrigerator Drain 1 ,> 0 ` aY 0 i t 0 0 0
Oil Sep (Gas Station) 6 ,, 0r,l 0 S t ; r
0 0 0
Rec. Vehicle Dump station 16 0 M„ 0 k`;,:" 0 0 0
Shower - Gang (per head) 1 1 y 0 �t , 0 ,. �` 0 0 0
- Stall 2 0 r � 0 ��° . 0 0 0
Sink - Bar /Lavatory 2 [ i,g , i,i-iii,it 0 iiiiiial 0 n t ' 0 0 0
v - a. .s Er e te rz m a"a
- Bradley 5 0 `��g 0 P 0 0 0
Commercial 3'' 0 0 6 2 6
- Service 3 a, '` 0 Y � 1 , , 0 k
,, a i 0 t . 0 0 0
AL 0 �'
Swimming Pool Filter N i�; 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 f 0 .',.,a,'' y 0 0 0
Water Closet - Toilet 6 x
Urinal 6 0 r , -: 0 r,, 0 0 0
Previous EDU Count ' 0 0
Capped EDU Credit :g ' 0
TOTALS 0 0 0 0 3 8 3 8
Current Fixture Value 8 divided by 16 = 0.5 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 8 divided by 16 = 0.5 over (under) $ 1,300.00
Enter EDU Change Here t. 5.: :;
Notes:
Authorized Name /Signature: A Date: ��j "p
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.
is \Building \Sewer Tally \SewerTallySheet.xls 7/1/05