Permit (175) q CITY OF TIGARD SEWER CONNECTION PERMIT
is COMMUNITY DEVELOPMENT Permit#: SWR2015-00235
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/05/2016
g 559
Parcel: 1 S136DC04500
Jurisdiction: Tigard
Site address: 7501 SW DARTMOUTH ST 100
Project: Winco Subdivision: 1995-013 PARTITION PLAT Lot: 2
Project Description: 1.13 EDU increase. Installing sushi kiosk within store.
Contractor: Owner: WINCO FOOD LLC
ATTN:TAX DEPARTMENT
PO BOX 5756
BOISE, ID 83705
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 01/04/2016 $5,763.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 1.13
Total $5,763.00
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: (. _ eTrttitlewBignature:
Call 503.639.4175 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
Tcnant Name. Winco-Sushi Kiosk SWR# 2015-00235
Site,lddress: 7501 SW Dartmouth#100 PJAI# 2015-00433
Parcel#: 1S136DC04500
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Ba tine /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 irator 1 0 0 0 0 0
Dishwasher: -Commercial 4 1 0 0 1 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 0 0 0 0
-3 inch 5 0 0 3 15 3 15
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 IIP) 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 Se 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 0 0 0
Bradley 5 0 0 0 0 0
Com/Scrv/Util-Food Related 3 0 0 1 3 1 3
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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOT,U,S H 0 0 1 0 1 0 1 4 1 18 1 4 1 18
Current Fixture Value 18 divided by 16= 1.125 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 18 divided by 16= 1.125 over (under) S 5,763.00
Enter EDU Change Here 1.130
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes: 2 of the food related sinks drain into the floor sinks and are not required by CWS to be charged SDC fees.
Authorized Name/Signature: Debbie Adamski Date: 12/30/2015
Building Division
IN ote: 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'1'igard Building Division to redeem credits towards future system development charges.
1:ABuilding\Sewer TallyASewerl'alIvSheet_5100_070115.xlsx