Permit CITY OF TIGARD SEWER CONNECTION PERMIT
s • COMMUNITY DEVELOPMENT Permit #: SWR2012 00109
T I GAP D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/11/2012
Parcel: 1S 126DCO3300
Jurisdiction: Tigard
Site address: 9900 SW GREENBURG RD 235
Project: Dr. Vaughn Subdivision: LEHMANN ACRE TRACT Lot: 4 -5
Project Description: .5 EDU Increase
Contractor: Owner. ATHERTON REALTY PARTNERSHIP
2100 S WOLF
DES PLAINES, IL 60018
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 06/11/2012 $2,250.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .5
Total $2,250.00
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 suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. Tho • - • • set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUNC b, calling 503.232. •8 = 1.800.332.2344.
Issue By: /4 �� Permittee Signature. -
Call 503.639.4175 by 7:00 a.m. for the next available inspection ate.
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.
A
IIIII u Accumulative Sewer Tally Tenant Name: Dr Vaughn SWR # 2012 -00109 .
TI GARD Site Address: 9900 SW Greenburg Rd, Ste. 235 PLM # 2012 -00158
Parcel #: 1S126DCO3300
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: - "Cub /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 1 -IP) 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:
- Lay/Bar - Non -Food Related 2 0 0 3 6 3 6
- 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 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 8 _ 4 8
Current Fixture Value 8 divided by 16 = 0.5 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 8 divided by 16 = 0.5 over (under) $ 2,250.00
Enter EDU Change Here 0.5
Notes:
Authorized Name /Signature: Dianna Howse , . Date: 6/6/2012
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.
I:\ Building \Sewer Tally \SewerfallySheet- 4500.xls 01/18/12