Permit CITY OF TIGARD SEWER CONNECTION PERMIT
111 COMMUNITY DEVELOPMENT Permit ii: SWR2013 00119
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718 2439 Date Issued: 06/05/2013
Parcel: 2S 101 AA06400
Jurisdiction: Tigard
Site address: 12323 SW 66TH AVE
Project: Selectron Subdivision: WEST PORTLAND HEIGHTS Lot: 32
Project Description: .5 EDU increase
Contractor: Owner: STONER, DAVID S
338 SE SPOKANE ST
PORTLAND, OR 97202
PHONE: PHONE: 503 - 597 -3303
FAX
FEES
Description Date Amount
Specifics: Sewer Connection Fee 06/05/2013 $2,332.50
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .5
Total $2,332 50
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 rules are - t forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUNC by ailing 503.232.198' or :.3.332.2344.
� l
Issued B : ��� /y i , Permittee Signatur= l �
io
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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
a
0 Tenant Name: Selectrun S \C'R # :2013-00119
T I G A R U Site Address:' 12323 SW 66th Ave PI AI # 2013 -00168
Parcel #:' 2S 101 AA06400
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Baptistry/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
- 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
- Industnal (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:
- Lav /Bar - Non -Food Related 2 0 1 2 1 2 0 0
- 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 1 6 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 _ 1 2 3 10 2 8
Current Fixture Value 8 divided by 16 = 0.500 Current EDU 1 EDU = $4,665.00
Previous Fixture Value 0 divided by 16 = 0.000 Previous EDU
Change 8 divided by 16 = 0.500 over (under) S 2,332 50
Enter EDU Change Here! 0.500
Notes:
Authorized Name/Signature: Debbie Adamski Date: 6/5/2013
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.
1. \ Building \Scwer Tally \Sewer 1'allyShect- 4665.xls 07/01/12