Permit 'hi__..,, CITY OF TIGARD SEWER CONNECTION PERMIT
r 'a. COMMUNITY DEVELOPMENT Permit#: SWR2015 00120
Date Issued. 10/13/2015
TIGARD 13125 SW Hall Blvd,Tigard OR 97223 503 718 2439 Parcel: 1S1260000300
Jurisdiction: TIGARD
Site address: 9642 SW WASHINGTON SQUARE RD G12
Project: Lolli&Pop's Subdivision VASHINGTON SQUARE ESTATES NO Lot: S
Project Description: 63 EDU Increase
Contractor: Owner. PPR WASHINGTON SQUARE LLC
PO BOX 847
CARLSBAD, CA 92018
PHONE. PHONE
FAX
FEES
Description Date Amount
Specifics: Sewer Connection Fee 10/13/2015 $3,213.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .63
Total $3,213 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 callin 3 2 1987 or 1 800 332 2344
Issued By: J t �G_��44 /, Permittee Signatur \`�-
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
0
"Tenant Name: Lollt& Pops SWR# 2015-00120
Site Address 9642 SW Washington Square Rd PI,N1 # 2015-00344
S7.2--,'k-+v Parcel# 1S 1260000300
Fixture Value Previous Previous Credits Capped fixture Diorite New New
# value count capped#s value count added# added value total#5 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. - [ach Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspiratoi 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
I?ve Wash 1 0 0 0 0 0
Hoot Diam/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
-Cat Wash 6 0 0 0 0 0
Garbage Disposal:
- Domestic(to 3/4 I I P) 16 0 0 0 0 0
-Commercial (to 5 I-1 P) 32 0 0 0 0 0
- Industrial (over 5 I-I P) 42 0 0 0 0 0
Ice iMlachine/Refrigerator Drain 1 0 0 0 0 0 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) 1 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink
-I,av/Bar-Non-Food Related 2 0 0 4 8 4 8
-Biadlev 5 0 0 0 0 0
-Com/Set./Unl- 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 I?xtractot 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous [DU Count 0 0
Capped [DU Credit 0
'I'O'I'A1,S 0 0 0 0 5 10 5 10
Current Fixture Value 10 divided be 16= 0 625 Current IiDU 1 EDU = $5,100.00
Previous Fixture Value 0 divided by 16= 0 000 Previous[DU
Change 10 divided by 16= 0 625 over (under) S 3,213.00
Enter EDU Change Here 0.630 '
'Round C?DUs to the neatest I/100th a count ending in 005 shall be rounded up to 01,and a count ending in.014 of less shall be rounded down to.01.
Notes.
Authorized Name/Signature: Debbie Adamskr Date: 10/13/2015
Building Division
Note: The property owner shall retain the ORIGINAI,sewer tally record. 1 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\Sewer I'allySheet_51111_I71)1 15 xis).