Permit ,t CITY OF TIGARD SEWER CONNECTION PERMIT
11111 ° ' COMMUNITY DEVELOPMENT Permit#: SWR2016-00030
T IGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/23/2016
Parcel: 1S 1260000300
Jurisdiction: Tigard
Site address: 9374 SW WASHINGTON SQUARE RD R05
Project: Verizon Subdivision: VASHINGTON SQUARE ESTATES NO. Lot: S
Project Description: Adding(1)drinking fountain(no drain),(1)primer&(3)water heaters.Capping(1)water closet.Replacing/relocating
(3)sinks&(2)water closets.
Contractor: Owner: PPR WASHINGTON SQUARE LLC
PO BOX 847
CARLSBAD, CA 92018
PHONE PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 02/23/2016 $1,275.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .25
Total $1,275.00
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 s 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 calling 503. .198 or 1.800.332.2344.
Issyed By: , Permittee Signa ure:
Call 503.639.4175 by 7:00 a.m.for the next available inspect'•n 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 Tall-
11 .
Tenant Name: Verizon Wheless SWR# 2016-00030
I K..\ten
Site Address: 9374 SW Washington Slum:Rd R05 PI NI# 2016-00090
Parcel#: 1S1260000300
Fixture \alue Previous Pi,ci>us I.redits Capped Fixture I.iv I r, New New
# ,.iluc count capped#s v:due 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 I 0 0 0 0 0
I I c Wash I 0 0 0 0 0
I Ioor Drain/Sink: -2 inch 2 0 0 0 0 0
-3 inch 5 0 0 2 10 2 10
-4 inch 6 0 0 0 1) 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 11P) 16 0 0 0 0 0
-Commercial(to 5 1IP) 32 0 0 0 0 0
-Industrial(over 5 11P) 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 Ri LI,J 2 0 (I 0 II 0
-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 0 II 0
Water Extractor 6 0 0 0 1) 0
Water Closet-Toilet 6 0 1 6 0 -1 -6
Urinal 6 0 II 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 1 6 2 10 1 4
Current Fixture Value 4 divided by 16= 0.250 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 4 divided by 16= 0.250 over (under) $ 1,275.00
Enter EDU Change Here 0.250 *
*Round I l)Us to the nearest 1/100th: a count ending in.005 shall he round,d up to.01,and a count ending in.014 or less shall he rounded down to.01.
Notes:
Authorized Name/Signature: Debbi/ \damski Date: 2/23/2016
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 dc\cl,pment charges.
I:\Buil ding\Sewer'Tally\SewerTallySheet_5100_070115.xlsx