Permit q CITY OF TIGARD SEWER CONNECTION PERMIT
1111 I COMMUNITY DEVELOPMENT Permit#: SWR2014-00025
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/26/2014
Parcel: 1 S 135BD01200
Jurisdiction: Tigard
Site address: 9800 SW SHADY LN
Project: Portland NCS Subdivision: MEADOW VIEW Lot: 8
Project Description: .25 EDU increase
Contractor: Owner: BURDICK-FORBES INVESTMENTS LLC
BY DONALD C BURDICK
434 RIDGEWAY RD
LAKE OSWEGO, OR 97034
PHONE PHONE:
FAX:
FEES
Description Date Amount
Specifics:, Sewer Connection Fee 03/26/2014 $1,824.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .5
Total $1,824.00
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 b 03.232.1987 or 1.800.332.2344.
Issued y: i Permittee Signature:
i
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
111 a Tenant Name: Portland National Cremation Society SWR# 2014-00025
I' <;n tt i> Site Address: 9800 SW Shady Lane PLM# 2014-00082
Parcel#: 1S135BD01200
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# 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
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 1 2 0 -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 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
Living Unit 16 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:
-Lay/Bar-Non-Food Related 2 0 0 1 2 1 2
-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 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 2 8 1 6
Current Fixture Value 6 divided by 16= 0.375 Current EDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 6 divided by 16= 0.375 over (under) $ 1,824.00
Enter EDU Change Here 0.380
Notes:
Authorized Name/Signature: Debbie Adamski/Branden Taggart Date: 3/25/2014
Building Division
rote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
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