Permit CITY OF TIGARD SEWER CONNECTION PERMIT
1111 2 COMMUNITY DEVELOPMENT Permit #: SWR2012 -00083
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/11/2012
Parcel: 1 S 135AB01003
Jurisdiction: Tigard
Site address: 10300 SW GREENBURG RD 110
Project: Terra Staffing Subdivision: METZGER, TOWN OF Lot: 9
Project Description: .3 EDU increase
Contractor: Owner: LINCOLN CENTER LLC
BY SHORENSTEIN PROPERTIES LLC
555 CALIFORNIA ST 49TH FL
SAN FRANCISCO, CA 94104
PHONE: PHONE: 513 - 619 -3200
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 05/11/2012 $1,350.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .3
Total $1,350.00
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 . - done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if
work is su•.ended for e the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. hose rules are s orth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUNC .y calling 503.232.7 or 8i r 32.2344.
/,
Issued ' : l� ! / Permittee Signature: ,
Call 503.639.4175 by 7:00 a.m. for the next available inspection e.
This permit card shall be kept in a conspicuous place on the job site until cop etion of the project.
Approved plans are required on the job site at the time of each inspection.
- n
Tenant Name: Terra Staffing Accumulative Sewer Tally
SWR # 2012 -00083
Site Address: 10300 SW Greenburg Rd #110 PI.M # 2012 -114
TIGARD"
Parcel #: 1S135AB01003
Fixture Value Previous Previous Credits Capped Fixture Fixture Ncw 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 1 2 1 2
Drinking Fountain 1 0 0 0 0 0
Eyc 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 I-IP) 16 0 0 0 0 0
- Commercial (to 5 14P) 32 0 0 0 0 0
- Industrial (over 5 I -IP) 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 1 2 1 2
- Bradley 5 0 0 0 0 0
- Com /Scrv/Util - Food Related 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 2 4 2 _ 4
Current Fixture Value 4 divided by 16 = 0.3 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 4 divided by 16 = 0.3 over (under) $ 1,350.00
Enter EDU Change Here 0.3
Notes:
Authorized Name /Signature: Debbie Adamski 0 Date: 5/11/2012
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. I f 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 \ SewerTally \SewerTallySheet- 4500.xls 01/18/12