Permit y n CITY OF TIGARD SEWER CONNECTION PERMIT
2 COMMUNITY DEVELOPMENT Permit#: SWR201300197
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/07/2013
Parcel: 2S 112ACO2100
Jurisdiction: Tigard
Site address: 14875 SW 72ND AVE
Project: Ortho-Med Subdivision: FANNO CREEK ACRE TRACTS Lot: 48
Project Description: Interior plumbing for TI:Adding(1)sink,(1)breakroom sink,(1)shower stall,and(1)water closet.
Contractor: Owner: RSD PROPERTY LLC
3208 SE 13TH AVE
PORTLAND,OR 97202
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 11/07/2013 $3,600.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .75
Total $3,600.00
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 sus------- • more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted • the Oregon Utility Notification
Center. ose rules ar- set f••• in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a •• •f the rules or direct questions
to OW by calling 503.232. •: or 1 :•1.332.2344. /
Is-ued By: �/ Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspectio �te.
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.
rag.,
Accumulative Sewer Tally
1111: Tenant Name: ORTI-IO-MED SWR# SWR2013-00197
Site Address: 14875 SW 72ND AVE PI,N1 # P1,M2013-00402
MON Parcel#: 2S112ACO2100
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
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 I-IP) 16 0 0 0 0 0
-Commercial(to 5 I-IP) 32 0 0 0 0 0
-Industrial(over 5 FIP) 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:
- l,av/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 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
'I'O'1'AI,S 0 _ 0 0 0 4 12 4 12
Current Fixture Value 12 divided by 16= 0.750 Current EDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 12 divided by 16= 0.750 over (under) S 3,600.00
Enter EDU Change Here 0.750
Notes:
Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 11/7/2013
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.
I:\Building\Sewer Tally\Sewcr'fallySheet_4800._070113.xlsx