Permit CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2013 00195
-TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/31/2013
Parcel: 2S102AA00905
Jurisdiction: Tigard
Site address: 12000 SW MAIN ST
Project: Sierk Orthodontics Subdivision: PAYLESS SHOPPING CENTER Lot: 5
Project Description: .5 EDU increase
Contractor: Owner: HAAGEN,GARY L&CANDACE C TRS
2514 SE 112TH AVE
VANCOUVER,WA 98664
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 10/31/2013 $2,400.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .5
Total $2,400.00
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 suspend for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. se rules a = set forth in OAR 952-001-0010 through OAR 952-001-0090. You may ob • a copy of •- s or s'rect questions
to OUN y calling 503.232.••, or .800.332.2344.
Is ed By: , I /- I Permittee Signature:
• Call 503.639.4175 by 7:00 a.m.for the next available inspection d e.
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
11,11 a
C Tenant Name:;Sierk Orthodontics SWR#'2013-00195
Site Address:!12000 SW Main St PLNI #.2013-00392
TIGARD
Parcel#: 2S102AA00905
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#5 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 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 1-IP) 16 0 0 0 0 0
-Commercial (to 5 I-IP) 32 0 0 0 0 0
-Industrial (over 5 I-1P) 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 3 6 3 6
-Bradley 5 0 0 0 0 0
-Com/Serv/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 EDU Credit 0
TOTALS 0 0 0 0 4 8 4 . 8
Current Fixture Value 8 divided by 16= 0.500 Current[.DU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 8 divided by 16= 0.500 over (under) _S_ 2,400.00
Enter EDU Change Here 0.500
Notes:
Authorized Name/Signature:jDebbie Adamski Date:I 10/31/2013 -
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. I f 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:A Building\Sewer Tally\Sewer TallyShect_4800._0701 l3.xlsx