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Permit . a CITY OF TIGARD SEWER CONNECTION PERMIT COMMUNITY DEVELOPMENT PERMIT #: SWR2007 - 00068 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 3/14/2007 PARCEL: 25101 DA - 00800 SITE ADDRESS: 07105 SW VARNS ST 100 ZONING: C -P SUBDIVISION: VARNS ACRES LOT: 011 JURISDICTION: TIG PROJECT: VARNS STREET BUILDING Project Description: .1 EDU increase. TENANT NAME: VARNS STREET BUILDING CWS NO: FIXTURE UNITS: CLASS OF WORK: ALT DWELLING UNITS: 0.1 TYPE OF USE: CMS NO. OF BUILDINGS: INSTALL TYPE: BUSWR IMPERV SURFACE: Owner: FEES SYMONDS EVANS & COMPANY PC 7105 SW VARNS RD SUITE 200 Description Date Amount TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 3/14/2007 $270.00 Phone: 503 - 597 -7350 Total $270.00 Contractor: REQUIRED ITEMS AND REPORTS Contact #: 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 follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. 4 Issue • / / ,�.' Permittee Signature: Call 503.639.4175 by 7:00 a.m. for an inspection that business day. 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. Accumulative Sewer Tally Parcel # 2S101 DA -00800 P , Tenant Name: Varns Street Building This SWR# 2007 -00068 Site Address: 7105 Sw Varns St This PLM# 2007 -00105 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value capped off value added added total total count off # s count N value H 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 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 - 3inch 5 0 0 0 0 0 - 4inch 6 0 0 0 0 0 - Car Wash Dm 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 1 2 1 2 Sink- Bar /Lavatory 2 0 0 0 0 0 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 0 0 0 - Service 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 1 2 1 2 Current Fixture Value 2 divided by 16 = 0.1 Current EDU 1 EDU = $ 2,700 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 2 divided by 16 = 0.1 over (under) $ 270.00 Enter EDU Change Here 0.1 Notes: Authorized Name /Signature: Debbie Adamski Date: 3/14/2007 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 \ Forms \ SewerTallySheet.xls 02/02/07