Permit n CITY OF TIGARD SEWER CONNECTION PERMIT
4 ' COMMUNITY DEVELOPMENT Permit#: SWR2015-00042
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/27/2015
Parcel: 2S112DC00701
Jurisdiction: Tigard
Site address: 15989 SW 72ND AVE
Project: Domino's Subdivision: FANNO CREEK ACRE TRACTS Lot: 39
Project Description: .56 EDU increase
Contractor: Owner: PACIFIC REALTY ASSOCIATES
ATTN: N PIVEN
15350 SE SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 04/27/2015 $2,744.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .56
Total $2,744.00
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. ose rules a set •-• in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy • the r •s/ direct questions
to 0 C by calling 503.232. •87 or 1 ,.•332.2344.
ssued By: / / 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
NO( Tenant Name: Domino s SWR# 2015-00042
Site Address: 15989 S\\ -2nd .\vc PLM# 2015-00123
TIGARI)
I'arc(l 2S112DC00701
Fixture \.:lt:, Previous Previous Credits Capped Fixture Fixture New New
# Aloe count_ capped#s \.due count added L' 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: - I?ach 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 2 .4 0 -2 -4
-3 inch 5 0 0 0 0 0
-4 inch 6 0 I) 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 II 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 I 1 1 1
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) I 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 (I 0 0 0
-Bradley 5 0 (1 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
Swimming Pool Filter • I 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 I 6 1 6
Urinal 6 0 0 1 6 1 6
Previous EDU Count (I 0
Capped EDU Credit 0
TOTAIS 0 0 2 _ 4 3 13 1 9
Current Fixture Value 9 divided by 16= 0.563 Current EDU 1 EDU = $4,900.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 9 divided by 16= 0.563 over (under) $ 2,744.00
Enter EDU Change Here 0.560
Notes:
Authorized Name/Signature: Debbie.\damski Date: 4/27/2015
Building Division
Note: 'Ihe 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'Figard Building Division to redeem credits towards future system development charges.
I:\Building\Sewer Tally\SewerTallySheet_4900._070114.xlsx