Permit n CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2013 -00125
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/19/2013
Parcel: 1 S135BD00100
Jurisdiction: Tigard
Site address: 9600 SW OAK ST 570
Project: Houser & Allison Subdivision: ASHBROOK FARM Lot: PTS 5 &
Project Description: .25 EDU increase.
Contractor: Owner: SUN LIFE ASSURANCE CO OF CANADA
BY NORRIS BEGGS & SIMPSON
121 SW MORRISON ST #200
PORTLAND, OR 97204
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 06/19/2013 $1,166.25
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: 4
Number of Dwelling Units: .25
Total $1,166.25
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. Those . • = set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direc questions
to OUNC by c. ing 03.232.1 • : or :10.332.2344. /
Issued By: / Permittee Signature: �j /4
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 pro 7
Approved plans are required on the job site at the time of each inspection.
` Accumulative Sewer Tally
s " Tenant Name: AMCI-IECK SWR # SWR2013 -00125
Site Address: 9600 SW OAK SUITE 570 P1 ,NI # PLM2013 -00183
Parcel #: 1S135BD00100
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
I:iye 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 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:
- I.av /Bar - Non -Food Related 2 0 0 1 2 1 2
- 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 [DU Credit 0
'l'O "1'AI.S 0 0 0 0 2 4 2 4
Current Fixture Value 4 divided by 16 = 0.250 Current EDU 1 EDU = $4,665.00
Previous Fixture Value 0 divided by 16 = 0.000 Previous EDU
Change 4 divided by 16 = 0.250 over (under) S 1,166.25
Enter EDU Change Here 0.250
Notes:
Authorized Name /Signature: BRANDEN TAGGARI X2439 . Date: 6/11/2013
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.
I:\ Building \Sewer Tally \Sewer l'allySheet- 4665.xls 07/01/12