Permit •
C ITY OF TIGARD SEWER CONNECTION PERMIT
ii DEVELOPMENT SERVICES PERMIT #: SWR2005 - 00206
,11. 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 7/19/2005
PARCEL: 1 S135BB -00501
SITE ADDRESS: 10575 SW CASCADE AVE 130 ZONING: I - P
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: .2 EDU increase.
TENANT NAME: HEMCON
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 0.2
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
AMB PROPERTY L P
BY TRAMELL CROW NW INC Description Date Amount
8930 SW GEMINI DR
BEAVERTON, OR 97008 [SWUSA] Sewer Connection Fee 7/19/2005 $520.00
Total $520.00
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 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.
ff
Issued by: `-:"27 �� 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 # ,1S135BB -00501
Tenant Name: Hemcon This SWR #2005 -00206
Site Address: 10575 SW Cascade Ave #130 This PLM# 2005 -00058 .
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 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 1 1 1 1
Eye Wash 1 0 0 1 1 1 1
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 Drn 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 0 0 0
Sink - Bar/Lavatory 2 0 1 2 0 -1 -2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 1 3 1 3
- Service 3 0 3 9 3 9 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 4 11 6 14 2 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) $ 520.00
Enter EDU Change Here' 0.2
Notes: Additional plumbing fixtures were added to Numbing permit after the rate changed on 7/1/05. So
a second permit was created instead of rev' ing the ' inal permit.
Authorized Name /Signature: Debbie Adam ki Date: 7/15/2005
B 'vision
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
hich must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\ Building \Sewer Tally \SewerTallySheet.xls 7/1/05