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Permit CITY OF TIGARD SEWER CONNECTION PERMIT r 3 ' COMMUNITY DEVELOPMENT Permit#: SWR2015-00065 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/07/2015 Parcel: 1S 134BC00300 Jurisdiction: Tigard Site address: 12266 SW SCHOLLS FERRY RD Project: Pacific Dental Services Subdivision: GREENWOOD TERRACE CONDO Lot: 17 Project Description: .5 EDU increase for TI. Contractor: Owner: FW OR-GREENWAY TOWN CENTER LLC ONE INDEPENDENT DRIVE, SUITE 114 JACKSONVILLE, FL 32202 PHONE: PHONE: 503-603-4709 FAX: FEES Description Date Amount Specifics: Sewer Connection Fee 07/06/2015 $2,450.00 Type of Use: COM Class of Work: ALT Install Type: Building Sewer Fixture Units: Number of Dwelling Units: .5 Total $2,450.00 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 by calling 503.232.1987 or 1.800.332.2344. Issued By: 1 11 J� Permittee Signature: l`\ _ i• A.0//fir _ 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. lig Accumulative Sewer Tally 'Tenant Name: Pacific Dental Services SWR# 2015-00065 Site Address: 12266 SW Scholls Ferry Rd PLM# 2015-00121 Parcel#: IS134BC00300 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 3 6 0 -3 -6 -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 lIP) 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 4 8 4 S -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 1 6 1 6 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 3 6 5 _ 14 2 _ 8 Current Fixture Value 8 divided by 16= 0.500 Current EDU 1 EDU= $4,900.00 Previous Fixture Value 0 divided by 16= 0.000 Previous EDU Change 8 divided by 16= 0.500 over (under) $ 2,450.00 Enter EDU Change Here 0.500 Notes: Authorized Name/Signature: Dianna Howse Date: 6/10/2015 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. I:\Building\Sewer Tally\SewerTallySheet_49i N 1._070114.xlsx