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HomeMy WebLinkAboutPermit Building 2013-5-8 • SPRINGFIELD 225 Fifth St 4k1 -- CITY OF SPRINGFIELD Springfield,OR97477 ilk& Phone: 541-726-3753 " OREGON Building I Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR2013-00653 www.springfield-or gav perm itcenteraspringfield-or.gov PROJECT STATUS: Issued ISSUED: 05/08/2013 EXPIRES: 11/03/2013 STATUS DATE: 05/08/2013 APPLIED: 03/29/2013 SITE ADDRESS: 211 17TH ST,Springfield,OR 97477 SCOPE: Single Family Residence ASSESOR'S PARCEL NO: 1703363102301 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: STR-Remodel OWNER: RISING PILLARS LLC Phone Number: 541-968-4375 ADDRESS: 1308 E St SPRINGFIELD OR 97477 CONTRACTOR INFORMATION Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 08/01/2025 L INSPECTIONS REQUIRED Inspections 1260 Framing Framing Inspection: Prior to cover and after all rough in inspections have been approved. 1430 Insulation Wall Wall Insulation: Prior to cover. 1440 Insulation Ceiling Ceiling insulation: Prior to cover. 1999 Final Building Final Building: After all required inspections have been requested and approved and the building is complete. By signature, I state and agree,that I have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances of the City of Springfield and the Laws of the State or Oregon pertaining to the work described herein, and that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time,that each address is readable from the street,that the permit card is located at the front of the property,and the approved set of plans will remain on the site at all times during jideconstruction. // GGEE Owner orA ta-TA If • o agon law requires you to Date follow rules adopted by the Oregon Utility NOTICE: ""` ' Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952.001- THIS PERMIT SHALL EXPIRE IF THE WORK 0090. You may obtain copies of the rules by AUTHORIZED UNDER THIS PERMIT IS NOT calling the center. (Note: the telephone COMMENCED OR IS ABANDONED FOR number for the Oregon Utility Notification ANY 180 DAY PERIOD. Center is 1-600-332-2344). Springfield Building Permit 5/8/2013 9:01:06AM Page 1 of 1 SPRINGFIELD CITY OF SPRINGFIELD 225 Fifth St TRANSACTION RECEIPT Springfield,OR 97477 OREGON 541-726-3753 811-SPR2013-00653 www.springfield-or gov 211 17TH ST perrnitcenter @springfield-or.gov RECEIPT NO: 2013000902 RECORD NO: 811-SPR2013-00653 DATE:05/08/2013 (DESCRIPTION ACCOUNT CODE/TRANS CODE'. AMOUNT DUE,_-J State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 13.98 Structural Building Permit Fee 224-00000-425602 1002 116.50 Technology fee(5%of permit total) 100-00000-425605 2099 5.83 TOTAL DUE: 136.31 ;,_PAYMENT TYPE. „I :PAYOR CASHIER:JLARSON COMMENTS -,. - ■ AMOUNT PAID - ; J Credit Card Richard Zink 136.31 003272 TOTAL PAID: 136.31 SPRINGFIELD'- CITY OF SPRINGFIELD ` 225 Fifth St TRANSACTION RECEIPT Spnngfeld,OR97477 OREGON 541-726-3753 811-SPR2013-00653 www.spnngfield-or.gov 211 17TH ST permitcenter @spnngfield-or gov RECEIPT NO: 2013000619 RECORD NO: 811SPR2013.00653 DATE:03/29/2013 lol4-'ItrI9ttl(ol4 fir` - --ti 'ate_..__ .:._ "_ o r o 15 : o e :±2.1%:2:1-1_4` AMOUNT_DUE:` Structural Plan Review Fee Residential 224-00000-425602 1061 75.73 TOTAL DUE: 75.73 :.•PAYMENT TYPE P OR...'cASITET oe6WLSev^ COMMENTS � '__ �� _ .-*ti=AMOUNT;PAID. 9, , is "c Credit Card RICHARD ZINK 75.73 051237 TOTAL PAID: 75.73 II tructural Permit Application DEPARTMENT USE ONLY S.RI..O m C1TYOF SPRINGFIELD;OREGON }°� " Sj3 po ONLY'� � Permit no.: , 225 Fifth Street♦Springfield,OR 97477•PH(541)726-3753•FAX(541)726-3689 "--- . Date: re/S -This permit is issued under OAR 918-460-0030. Permits expire if work is not started within 180 days of work is suspended for 180 days. LOCAL GOVERNMENT_,APPROVAL i .ti:-_ 'This project has final land-use approval. - - .- Signature: Date: FEE SCHEDULE This project has DEQ approval. 1. Valuation information• :.'' + " , Signature: - Date: (a)Job description: .Q i a .r../ ,.r�, _ Zoning approval verified: ❑ Yes ❑No Occupancy ►Z'3 �° `�Y Property is within flood plain: Yes ❑No Construction type: Y " „4,. r. VCAT.EGORYi:OFECONSTRUCT.IONix a 4. •X.�e ,-. is - �:;,«+ Square feet: ci 4e, ❑Residential ❑ Government ❑Commercial Cost per square foot: 'JOB SITE INF,ORMATION ':AND LOCATION '":+ `• . - Other information: Job site address: 2.1( 17 tit, 5Y Type of Heat: City: f',I,64ei k—fl State: O'(Z. ZIP: /Z127 . Energy Path: Subdivision: Lot no.: / �7brIC3 3-3G-'3i-[OZW1 ❑ °ew alteration ❑addition Reference: Taxlot:l?-O `` ' PROPERTY OWNER (b)Foundation-only permit? ❑Yes gNo Total valuation: Safe , Name:q(, Lt IG 49 6LAei7$ 1.-1--C--, 7 s 2 'Building=fp'es , Address: Y� (a) Permit fee(use valuation table): - $ 116 S.--j- City: fmic . , -__/ State: SOP ' ZIP.'" 4.7 (b)Investigative fee(equal to [2a]): $ Phone:f4(-142,- 4575 Fax: - - (c)Reinspection($ per hour): $ E-mail: !LZt7J-t�((,_t Q,C e-gyp,-, cent (number of hours x fee per hour) This installation is being made on residential or farm property owned by (d)Enter 12%surcharge(.12 x[2a+2b+2c]): $ /5 Ti i me or a member of my immediate famil pt from licensing . requirements under ORS 701.010. ' (e) Subtotal of fees above(2a through 2d) s ` .... . 3.Plan reuuewtfees .max:' Sign here: 7S- ' - • (a) Plan review(65%x permit fee[2a]): s CONTRACTOR INST- LATION:., -- (b)Fire and life safety(40%x permit fee[2a]): $ Business name: (c) Subtotal of fees above(3a and 3b): $ Address: 4,1VItscellangous`fees '. '5�� City: State: ZIP: .. .`..f? i. .c..:..,. (a) Seismic fee, I%(.01 x permit fee[2a]): $ Phone: - - Fax: - - TOTAL fees and surcharges(2e+3c+4a): S 7j/Z E-mail: CCB license no.: • Print name: Signature: 1. `, 11B CONTRACTOR INFORMATIONS - , ;,-:n ,'; Name CCB License Number Phone Number Electrical Plumbing Mechanical SPRINGFIELD - ' 225 Fifth St CITY OF SPRINGFIELD Springfield,OR 97477 n' ` s� Phone: 541-726-3753 OREGON Building / Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR2013-00656 www.springfield-or.gay permitcenter @springfield-or.gov PROJECT STATUS: Issued ISSUED: 05/08/2013 EXPIRES: 09/25/2013 STATUS DATE: 05/08/2013 APPLIED: 03/29/2013 SITE ADDRESS: 211 17TH ST,Springfield,OR 97477 SCOPE: Plumbing Only ASSESOR'S PARCEL NO: 1703363102301 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: PLM-Remodel OWNER: RISING PILLARS LLC Phone Number: 541-968-4375 ADDRESS: 1308 E St SPRINGFIELD OR 97477 L CONTRACTOR INFORMATION Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 08/01/2025 INSPECTIONS REQUIRED Inspections 3170 Underfloor Plumbing Underfloor Plumbing: Prior to insulation or decking. 3500 Rough Plumbing Rough Plumbing: Prior to cover and including required testing. 3999 Final Plumbing Final Plumbing: Wien all plumbing work is complete. By signature, I state and agree,that I have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances of the City of Springfield and the Laws of the State or Oregon pertaining to the work described herein,and that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time,that each address is readable from the street,that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during construction. /r / n Owner or Contractor `'nature Date ATTENTION: Oregon law requires you to - • follow rules adopted by the Oregon Utility '; :, ` , • Notification Center. Those rules are set forth NOTICE': in OAR 952-001-0010 through OAR 952-001- 0090. You may obtain copies of the rules by AUTHORI EID UNDER HPS PERM TEIS ONBOTK calling the center. (Note: the telephone number for the Oregon Utility Notification COMMENCED OR IS ABANDONED FOR . sr. Center is 1-800-332-2344y ANY 1.80 DAY PERIOD. Springfield Building Permit 5/8/2013 9:13:41AM Page 1 of 1 SPRINGFIELD CITY OF SPRINGFIELD =5.n ..e..- 225 Fifth St TRANSACTION RECEIPT Springfield,OR97477 OREGON 541-726-3753 811 SPR2013-00656 www.springfield-or.gov 211 17TH ST permitcenter©springfield-or.gav RECEIPT NO: 2013000900 RECORD NO:811-SPR2013-00656 DATE:05/08/2013 {DESCRIPTION- ___�.____._� _ ACCOUNTCODE/TRANS,CODE • _'_. AMOUNT-DUE Dishwasher 224-00000-425603 1005 19.00 Fixture 224-00000-425603 1005 57.00 State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 9.12 Technology fee(5%of permit total) 100-00000-425605 2099 3.80 ��-�--TOTAL DUE: 88.92 L PAYMENT TYPE • PAYOR CASHIER:JLARSON �� 'COMMENTS - -" ` „ AMOUNT PAID: ' . Credit Card Richard Zink 88.92 003272 TOTAL PAID: 88.92 • Plumbing Permit Application ; DEPARTMENT;USE ONLY5*-4; SPRINGFIELD i CITY OESPRINGFIEL6v DREGOO N " - Permit no.: S/3- D 6 6 +"„', +'t° ,`. >. m u.w2-` is, Y 3-� ' ,4�•,,A• •.' ,.�r,..:m t- 225 Fifth Street• Springfield,OR 97477 • PH(541)726-3753 • FAX(541)726-3689 Date: / This permit is issued under OAR 918-780-0060. Permits are issued only to the person or contractor doing the work. Permits expire if work is not started within 180 days of issuance or if work is suspended for 180 days. ict4 i "LOCAL,:GOVERNMENJAPPROVAL' ',n_ '. ` '- ft FEE;,SCHEDULE a .fil.Oi A ��', Zoning approval verified? ❑ Yes ❑ No s+Descrl tlon'{+ ,. t Cost z, , 2,,,f N,. .. P.. .. - t=N�,.,, F: , ts"•4, rOk yQ444-ea,a l cost .,; Sanitation approval verified? ❑ Yes ❑ No New residential CATEGORY OF CONSTRUCTION.` ; I bathroom/1 kitchen(includes:first R.Residential ❑ Government ❑ Commercial b00 feet maker,water/sewer lines,1,low-point $ }s+ bibs, ice maker, underJ7oor!ow-poin! q;:gJOB.,SITE ;INFORMATION;:SAND;tLOCATIONgiG': % '-Q drains and rain-drain packages) Job site address: 2,]i (2F _ vr-, 2 bathrooms/1 kitchen $374.00 $ 3 bathrooms/1 kitchen $439.00 $ City:! State;Qtte_ ZIP: 7477 Each additional bathroom(over 3) $95.00 $ Reference: Taxlot.: Each additional kitchen(over I) $95.00 $ %* , ,Z2_?,DESCRIPTION OF1.WORK atie.QOPtitE Residential fire sprinklers(includes plan review) itaizeieseciece off texr- Ic wr p", 0 to 2,000 square feet $58.00 $ l -- •oU.– - 2,001 to 3,600 square feet $116.00 $ 1 ;, PROPERTY=OWNER * ,:v ' O F ,v"; iA`' y. 3,601 to 7,200 square feet $174.00 $ 7,201 square feet and greater } $232.00 $ Name: IZVA ivitAs..kg I Manufactured dwelling or pre-fab(circle one) • Address: 1 C:),45, 1 c rt Connections to building sewer and $58.00 $ City: /��.[�, State:�L ZIP:977'7 water supply �`• Commercial, industrial,and dwellings other than one-or Phone:54(—14,5 .4 ' Fax: - - two-family E-mail: C+a�J . /frate� t— . � Minimum fee $58.00 . $ This installation is being made on residential or farm property Each fixture :/ 'f T owned by me or a member of my immediate family, and is Miscellaneous fees (l exempt from lice 'ng re under OAR 918-695-0020. 100' storm,sewer,water line $76.00 $ Signature: _.---1 - Each fixture,appurtenance,and piping $19.00 $ - .CONTRACTOR.It•i r fALLATION.._. -,,. :,/%Grs.,.te., Storm water retention/detention facility $19.00 $ Business name: OL Piping or private $19.00 $ Piping or private storm drainage $19.00 $ Address: systems exceeding the first 100 feet City: State: ZIP: Specialty fixtures $19.00 $ Reinspection(no.of hrs.x fee per hr.) $56.00 $ Phone: - - Fax: - - Special requested inspections(no.of E-mail: hrs.x fee per hr.) $58.00 $ CCB license no.: BCD license no.: Each additional inspection: (1) $58.00 $ Plumbing license no (Medtcaigas`pipmg144° _,s?° AB,:m.r,„ Minimum fee $ Print name: Enter value of installation and equipment$— Enter fee based on installation and equipment value. $ Signature: r,.'h zr ,,,- 57::kPPLICANTg USEelfileal ''O,' (A) Enter subtotal of above fees r�/!t� (Minimum Permit Fee$58.00) $ a� / (B)Investigative fee(equal to [A]) $ • (C)Enter 12%surcharge(.12 x [A+B]) $ 972, (ID)Technology Fee(5%of[A]) $ TOTAL fees and surcharges(A through D): /— 440-2500-1(I I/08/COM) • ny of -r-cy - SPRINGFIELD 225 Fifth St k CITY OF SPRINGFIELD Springfield,OR 97477 C Phone: 541-726- 3 oaeG°" Building / Residential Permit ' Inspection Phon 541-726-3769 . Fax: 541-726-3676 PERMIT NO: 811-SPR2013-00655 www.springfield-or.gov perm itcenter©springfield-or.gav PROJECT STATUS: Issued ISSUED: 05/08/2013 EXPIRES: 11/03/2013 STATUS DATE: 05/08/2013 APPLIED: 03/29/2013 • SITE ADDRESS: 211 17TH ST,Springfield,OR 97477 SCOPE: Mechanical Only ASSESOR'S PARCEL NO: 1703363102301 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: MEC-Remodel OWNER: RISING PILLARS LLC Phone Number: 541-9684375 ADDRESS: 1308 E St SPRINGFIELD OR 97477 L CONTRACTOR INFORMATION Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 . 08/01/2025 INSPECTIONS REQUIRED II Inspections 2300 Rough Mechanical Rough Mechanical: Prior to Cover 2999 Final Mechanical Final Mechanical: When all mechanical work is complete. By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances of the City of Springfield and the Laws of the State or Oregon pertaining to the work described herein, and that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time,that each address is readable from the street,that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during constructs r Owner or Contract. ignature Date ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth NOTICE: in OAR 952-001-0010 through OAR 952-001- THIS PERMIT SHALL EXPIRE IF THE WORK 0090. You may obtain copies of the rules by '.UTHORIZED UNDER THIS PERMIT IS NOT calling the center. (Note: the telephone 'OAQMENCED OR IS ABANDONED FOR number for the Oregon Utility Notification Center is 1-800-332-2344). .NY 180 DAY PERIOD. Springfield Building Permit 5/8/2013 9:04:29AM Page 1 of 1 • SPRINGFIELD rii CITY OF SPRINGFIELD • i ...._ :� TRANSACTION RECEIPT 225 ifthStOR97477 ONEGON 541-726-3753 811-S PR2013-00655 www.springfield-or.gov 211 17TH ST permitcenter@springfield-or.gov RECEIPT NO: 2013000901 RECORD NO:811-SPR2013-00655 DATE:05/08/2013 IDESCRIP_TION, ' .. ACCOUNTCODE/TRANS_CODE—' -AMOUNT_DUE.] First Appliance Fee 224-00000-425604 1006 79.00 Single-duct exhaust(bathrooms,toilet compartments, utility room: 224-00000-425604 1006 9.00 State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 10.56 Technology fee(5%of permit total) 100-00000-425605 2099 4.40 TOTAL DUE: 102.96 LPAYMENT TYPE . , 'FAVOR ` CASHIER:JLARSON •L,„,,,COMMENTS _ ;-.. "- " . I AMOUNT PAID ' , - j Credit Card ~Richard Zink �� _ 102.96 003272 TOTAL PAID: 102.96 DEPARTMENT USE ONLY > Mechanical Permit Application ,, rt;}'. @'xfk.ri 0,-1, r. � Y U-uw y#"v'.L fs +d+ YS'r'' �r£FtY s4 7f`a SPRINGFIELD -.1,7"-(3 O L tj x - Permit no.: V�� �.. CIT,Y OF SPRINGFIELD;OREGON . Eisk .,-: , r�o- 225 Fifth Street • Springfield,OR 97477 ♦ PH(541)726-3753 • FAX(541)726-3689 Date: This permit is issued under OAR 918-440-0050. Permits expire if work is not started within 180 days of issuance or if work is suspended for 180 days. °`r CATEGORY;`OFCONSTRUCTION ` {` FEE SCHEDULE Cost t Total .. ID Residential ❑Government ❑ Commercial cResldentlalti,i ,�"„�=,t;P,tx `s:`' rQJ , r-ea> ° 1*ncost;^li,i ?Li"ljt JOB''SITE INFORMATION ANDE,LOCATION , .';�. ,: - First Appliance / $79.00 $� Job site address: 2! 1 I 7 ,4_ �jT Furnace/burner including ducts and vents City: �e2. State:0 I Z-1P:4/7477' Up to IOOk BTU/hr. $17.00 $ Over 100k BTU/hr. $20.00 $ Reference: Taxlot:: I DESCRIPTION:OF WORK Unit he Heaters/stoves/vents - - - � Unit heater $17.00 $ I !-. 04 r. ,Q ___ i2I [cttia Wood/pellet/gas stove/flue $38.00 $ /t-h6--C er 'eve L5441 Repair/alter/add to heating appliance/ refrigeration unit or cooling system/ $58.00 $ x n tr t PRORERTY OWNER ov y 4 absorption system Name: rE.i& Lb( . /QL kii-,�j � Evaporated cooler $13.00 $ ¢/Q�{ /Address: " Vent fan with one duct/appliance vent $9.00 $fl—” '�/ Hood with exhaust and duct / $13.00 $of((_T) City: ep(-0, State: _ ZIP:C/7477 Floor furnace including vent $58.00 $ Phone:0041 _4 Fax: - - Gas piping E-mail: 1,� j2; Ci �-O�,Ca One to four outlets $7.00 $ This installation is being made on property owned by me or a Additional outlets(each) $4.00 $ member of my immediate family, and is exempt from licensing Air-handling units, including ducts requirements uu ORS 71 .0 e. Up to 10,000 CFM $11.00 $ Signature: 4 Over 10.000 CFM $20.00 $ t"4 t CONTRACTO N_ , LLATIONtS . `s Compressor/absorption system/heat pump Business name: rh _ Up to 3 hp/1 BTU $17.00 $ Up to 15 hp/500k k BTU $29.00 $ Address: - Up to 30 hp/1,000 BTU $43.00 $ City: State: ZIP: Up to 50 hp/1,750 BTU $57.00 $ Phone: - - Fax: - - Over 50 hp/1,750 BTU $95.00 $ ' E-mail: Incinerators Domestic incinerator $20.00 $ CCB license no.: - -- r-v Ep 7�,n+,:;A �, -cam _ �Commerciah� �a?�:• 'r�'� Print name: Enter total valuation of mechanical system and installation costs$ Signature: Enter fee based on valuation of mechanical system,etc. $ t *k'° 4 ' pi ,t " s 1 Colt„ ,Total Miscellaneous fees Items i ear x cos[,'., Reinspection $58.00 $ Specially requested inspections(per hr.) $58.00 $ Regulated equipment(unclassed) $13.00 $ Each additional inspection: (1) $58.00 $ 4 4?.r3`ati o'+'.',PAP.P,.LICKMT9USE ," " r, rea:' '''. (A)Enter subtotal of above fees(or enter set minimum fee of $79_00) $ el r,�/j,��t�� ' U (B) Investigative fee(equal to [A]) $ (C)Enter 12%surcharge(.12 x [A+B]) $ i_I /tr ( (D)Seismic fee, 1%(.01 x [Al) $ (E)Technology Fee(5%of[A]) $ (ra 11 yo � 440-2545-1(I 1/08/COM) TOTAL fees and surcharges(A through E): $ ��`l wZ96 Property Owner Statement Regarding Construction 'Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325 (2)) This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: • • I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or — Vi I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. • I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. Print Name of Permit a nt r Signature of Permit Apv ant Da A/ Permit#: S3—653 o cc ono. o f Address: 21/ I ] ' �� �rlv-ic P Q Ora 'gyp SirLI) CM- /2q)) F� N 2 Issued by: Date: 43.5-§ This Copy for Permit Offices