Permit CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2012 -00046
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/15/2012
Parcel: 1 S 136DCO2504
Jurisdiction: Tigard
Site address: 7275 SW DARTMOUTH ST 180
Project: Tigard Triangle Smiles Subdivision: HUNTER POLLOCK NO.2 Lot: G
Project Description: 1.0 EDU increase.
Contractor: Owner. AMERICAN INDUSTRIES INC
1750 NW FRONT AVE STE #106
PORTLAND, OR 97209
PHONE PHONE:
FAX:
• FEES
Description Date Amount
Specifics: Sewer Connection Fee 03/23/2012 $4,500.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: 10
Number of Dwelling Units: 1
Total $4,500.00
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 s - • - • - • •r more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by • - - • •n ' • ` ification
Center Those rules a - set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a • : • of the rul >- •r direct • - •ns /
to OU C by calling 503.23 19: or .:00.332.2344.
Iss ed By: " • _ •% J ` ( -- 4 1 Permittee Signature: -
Call 503.639.4175 by 7:00 a.m. for the next available inspectio = =.
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.
111 r Accumulative Sewer Tally
a
T enant Name: TIGARD TRIANGLE SMILES SWR # SWR2012 -00046
T1 GAR1) Site Address: 7275 SW DARTMOUTH AVE PI.,M # PLM2011 -00383
Parcel #: 1 S 136DCO2504
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 1 2 1 2
- 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 I -IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Scp (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 2 4 6 12 4 8
- Bradley 5 0 0 0 0 0
- Com /Sery /Util - Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 2 12 2 12 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 4 16 _ 10 _ 32 6 16
Current Fixture Value 16 divided by 16 = 1.0 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 16 divided by 16 = 1.0 over (under) $ 4,500.00
Enter EDU Change Here 1
Notes:
Authorized Name /Signature: BRANDEN TAGGART X2449 Date: 3/6/2012
Building Division
r ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
bmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \Building \Sewer Tally \ SewerTallySheet-4500.xls 01/18/12