Permit CITY OF TIGARD SEWER CONNECTION PERMIT
2 COMMUNITY DEVELOPMENT Permit#: SWR2016 00260
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/21/2016
Parcel: 2S106DB23700
Jurisdiction: Tigard
Site address: 17390 SW SABRINA AVE
Project: River Terrace Northwest Swim Center Subdivision: RIVER TERRACE NORTHWEST Lot: X
Project Description: 3.81 EDU's for new swim center
Contractor: Owner: ADLV LAND HOLDINGS LLC
BY FORSUM, MICHAEL
7600 E DOUBLETREE RANCH RD STE 1
SCOTTSDALE,AZ 85258
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Inspection-Commercial 07/21/2016 $45.00
Type of Use: COM Sewer Connection Fee 07/21/2016 $19,431.00
Class of Work: NEW
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 3.81
Total $19,476.00
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 .232.1987 or 1.800.332.2344.
Issued By: p� J Permittee Signature: ��
Call 503.639.4175 by 7:00 a.m.for the next available inspecti date.
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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
"Tenant Name: River Terrace Northwest Swim Center SWR# 2016-00260
TIGARD Site Address: 17390 SW Sabrina Ave PLM# 2016-00314
Parcel#: 2S 106DB23700
Fixture Value Previous T 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 1 2 1 2
Drinking Fountain 1 0 0 1 1 1 1
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 5 10 5 10
-3inch 5 0 0 0 0 0 1
-4 inch 6 0 0 1 6 1 6
-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 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 1 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) 1 0 0 0 0 0
-Stall 2 0 0 1 2 1 2
Sink:
-Lay/Bar-Non-Food Related 2 0 0 4 8 4 8
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 1 1 1 1
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 4 24 4 24
Urinal 6 0 0 1 6 1 6
Previous IMU Count 0 0 I
Capped EDU Credit 0
TOTALS 0 0 0 0 20 61 20 61
Current Fixture Value 61 divided by 16= 3.813 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 61 divided by 16= 3.813 over (under) $ 19,431.00
Enter EDU Change Here 3.810
*Round I?DUs 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:
Authorized Name/Signature: Debbie Adamski Date: 7/20/2016
Building Division
Note: The property owner shall retain the ORIGINAI,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 development charges.
I:A Building\Sewer Tally\SewerTallySheet_5100_070115.xlsx