Permit r :. t
CITY OF TIGARD ' 4 I SEWER CONNECTION PERMIT
u i/ dei; tom'
a . •= COMMUNITY DEVELOPMENT Permit#: SWR2013 00184
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/12/2013
Parcel: 1S 136DA00800
Jurisdiction: Tigard
Site address: 11538 SW PACIFIC HWY
Project: Black Rock Coffee Bar Subdivision: PFAFFLE PLAZA CONDO Lot: 2
Project Description: .81 EDU increase. 11/20/13,reprinted to correct address from 11540 to 11538 SW Pacific Hwy.
Contractor: Owner: HIGH HAT RESTAURANTS, INC
11530 SW PACIFIC HWY
TIGARD,OR 97223
PHONE: PHONE:
FAX:
1 FEES
Jt Description Date Amount
Specifics: Sewer Connection Fee 09/12/2013 $3,888.00
Type of Use: COM
Class of Work: ALT
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: .81
Total $3,888.00
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. Those rules are 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 by calling 503.232.1987 or 1.800.332.2344.
Ck::-. SszjigdALE____Issued By: Permittee Signature: afe`A'
Call 503.639.4175 by 7:00 a.m.for the next available inspection date. U7'
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.
IN Accumulative Sewer Tally
v
p 'Tenant Name: Black Rock Coffee "Rry Ism'1'O CORRECT'ADDRvsS" S\VR# 2013-00184
TIGARD
Site Address: 11538 SW Pacific Hwy(prey address 11540 SW Pac I Iwv) ' ` ; PI,N1 # 2013-00315
Parcel#: 1S136DA00800
Is a .. Cla
Fixture Value Previous Previous Credits Capped '>i- 01517ture New New
# value count capped#s value count 'dd added value total#s total 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
Eve 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
-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:
-Lav/Bar-Non-Food Related 2 0 0 2 4 2 4
-Bradley 5 0 0 0 0 0
-Cum/Sery/IJnl-Food Related 3 0 0 1 3 1 3
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 _ 0 0 4 13 4 13
Current Fixture Value 13 divided by 16= 0.813 Current EDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous C?DU
Change 13 divided by 16= 0.813 over (under) S 3,888.00
Enter EDU Change Here' 0.810
Notes: Pre-fab structure being placed on site. These are the fixtures existing in this structure.
Authorized Name/Signature: Debbie Ada,nski Date:', 9/12/2013
Building Division
Note: The property owner shall retain the ORIGIN Al,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:A Building\Sewer Tally\Se. er'hallySheet_480U._U7U113.xlsx
•
CITY OF TIGARD SEWER CONNECTION PERMIT
n
1111 2 COMMUNITY DEVELOPMENT Permit#: SWR2013 00184
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/12/2013
Parcel: 1 S 136DA00800
Jurisdiction: Tigard
Site address: 11540 SW PACIFIC HWY
Project: Black Rock Coffee Bar Subdivision: PFAFFLE PLAZA CONDO Lot: 2
Project Description: .81 EDU increase
Contractor: Owner: HIGH HAT RESTAURANTS, INC
11530 SW PACIFIC HWY
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 09/12/2013 $3,888.00
Type of Use: COM
Class of Work: ALT
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: .81
Total $3,888.00
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 suspende• • more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. T • e 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 • calling 503.232.19:. • :9.332.2344.
Issu=• By: 14PLAkir Permittee Signature:
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.
III a
I Tenant Name: Black Rock Co
Accumulative Sewer Tally
sax/it# 2013-00184
TIGARD Site Address: 11540 SW Pacific Hwy PI,\I # 2013-00315
Parcel#: 1S136DA00800
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#5 total values
Baptisery/Font 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-lacuzzi/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
Lye 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 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:
-Lav/Bar-Non-Food Related 2 0 0 2 4 2 4
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 1 3 1 3
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
TO'l'AI.S 0 0 0 0 4 13 4 13
Current Fixture Value 13 divided by 16= 0.813 Current EDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous[DU
Change 13 divided by 16= 0.813 over (under) S 3,888.00
Enter EDU Change Here 0.810
Notes: Pre-fab structure being placed on site. 'These are the fixtures existing in this structure.
Authorized Name/Signature: Debbie Adamski Date: 9/12/2013
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\Sewcr'I'allySheet_4800._0701 13.xlsx