Permit 11111 CITY OF TIGARD SEWER CONNECTION PERMIT
s ° COMMUNITY DEVELOPMENT Permit#: SWR2015-00008
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/02/2015
Parcel: 1 S136CD00100
Jurisdiction: Tigard
Site address: 11705 SW PACIFIC HWY X
Project: Donut Day Subdivision: 2006-016 PARTITION PLAT Lot: 3
Project Description: .63 EDU increase
Contractor: Owner: PACIFIC CROSSROADS PROPERTIES IN
BY WYSE INVESTMENT SERVICES CO
1501 SW TAYLOR ST STE 100
PORTLAND, OR 97205
PHONE: PHONE:
FAX:
• FEES
Description Date Amount
Specifics: Sewer Connection Fee 02/02/2015 $3,087.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .69
Total $3,087.00
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
Cen . 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
t UNC by calling 503.232.19: 811.332.2344.
Issued By: ' \ / 01, I / 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.
Accumulative Sewer Tally
1,1,0,„ Tenant Name: Donut Day SWR# 2015-00008
Site Address: 11705 SW Pacific 1 Iwy Suite X PLM# 2015-00031
I l l }I'.)1
Parcel#: 1S 136C D00100
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# ,.clue count capped#s \.due count added#t 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 I 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 HP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain I 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:
-Lav/Bar-Non-Food Related 2 0 0 1 2 1 2
-Bradley 5 0 0 0 0 0
-Com/Scrv/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 0 0 3 10 3 10
Current Fixture Value 10 divided by 16= 0.625 Current EDU 1 EDU= $4,900.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 10 divided by 16= 0.625 over (under) S 3,087.00
Enter EDU Change Here 0.630
Notes: 1 of 2 floor drains is a hub drain,do not need to count hub drains per CMS.
Authorized Name/Signature: Debbie Adamski Date: 1/28/2015
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\tiewerTallytiheet_49(M)._))70114.xlsx