The URL can be used to link to this page

Home My WebLink AboutPermit Building 2008-3-12 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line CITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2008-00062 ISSUED: 03/12/2008 APPLIED: 01115/2008 EXPIRES: 09/12/2008 VALUE: $ 18,900.00 SITE ADDRESS: 3959 E ST ASSESSOR'S PARCEL NO.: 1702311403500 Springfield TYPE OF WORK: Single Family Residence TYPE OF USE: Addition Residential PROJECT DESCRIPTION: Addition to single family residence Owner: DOMINGUEZ JUAN J Address: 3959 E ST SPRINGFIELD OR 97477 Contractor Type General Electrical Mechanical Plumbing Contractor OWNER OWNER OWNER OWNER # of Units: Primary Occupancy Group: R-3 Secondary Occupancy Group: Primary Construction Type VB Secondary Construction Type: # of Bedrooms: Frontyard Setback: Side 1 Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Improvements: Storm Sewer Available: Special Instruction: [~Ol~CE: 711;{J f;:~,MI7 .:, AUTHORIZED U COMMENCED OR IS ABANDONED FOR ANY 180 DAY PERIOD. 5.00 Phone Number: 541-726-3133 I CONTRACTOR INFORMATION I License Expiration Date Phone \ w requires you .t~ PT:ENi\ON: oref~~ b~ the Oregon Ut~~~~h h)\\o"J rules adop ihose rules are se~ 001 t\\~~~i~C.~:~~~_?~~t;~i n through ~~~v9~~~:" h~ BUILDING INFORMA" Y obtain ~of'~~he te\epho~e \\'og the center. ( 0 ~tility NotiUca\\on # of Stories: ca ~ber lor the. Olego~~~j!(44). Height of Struct~Ve centeJg1ild-80~~Ft 1st Floor: Type of Heat: Sq Ft 2nd Floor: Water Type: Sq Ft Basement: Range Type: Sq Ft Garage/Carport Energy Path: Path 1 Sq Ft Other: Sprinkled Building. n/a Occupant Load: 180 I DEVELOPMENT INFORMATION I REQUIRED PARKING Total: Handicapped: Compact: Overlay Dist: # Street Trees Rqd: Paved Drive Rqd: % of Lot Coverage: ~''1'~ If:.,L.E ~ r;;: " Sidewalk Type: Downspouts/Drains: Notes: storm water will tie into existing gutters Pa2e 1 of3 CITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2008-00062 ISSUED: 03/12/2008 APPLIED: 01/15/2008 EXPIRES: 09/12/2008 VALUE: $ 18,900.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line I Valuation Descrintion I Descriution $ Per Sq Ft or multiplier $105.00 Square Footage or Bid Amount 180.00 DweIIinl!s Tvpe of Construction V Wood Frame Total Value of Project ~ Value Date Calculated $18,900.00 $18,900.00 01115/2008 Fee Description Amount Paid Date Paid Receipt Number Plan Review Residential $127.31 1/15/08 1200800000000000046 -Mechanical Issuance Fee- $20.00 3/12/08 2200800000000000319 + 10% Administrative Fee $35.69 3/12/08 2200800000000000319 + 12% State Surcharge $41.74 3/12/08 2200800000000000319 + 5% Technology Fee $17.39 3/12/08 2200800000000000319 Add, Alter, Extend Circ $48.00 3/12/08 2200800000000000319 Add, Alter, Extend Circ Ea Add $4.00 3/12/08 2200800000000000319 Building Permit $195.86 3/12/08 2200800000000000319 Fire SF Fee - Residential $9.00 3/12/08 2200800000000000319 Fixture $48.00 3/12/08 2200800000000000319 Minimum/Adjustment Mechanical $43.00 3/12/08 2200800000000000319 Minimum/Adjustment Plumbing $2.00 3/12/08 2200800000000000319 Sanitary Sewer - Improvement $142.83 3/12/08 2200800000000000319 Sanitary Sewer - Reimbursement $187.83 3/12/08 2200800000000000319 SDC Sanitary/Storm Admin $24.60 3/12/08 2200800000000000319 Storm Drainage Impervious Area $161.25 3/12/08 2200800000000000319 Vent Fan $7.00 3/12/08 2200800000000000319 Total Amount Paid $1,115.50 I Plan Reviews' Initial Review 01/16/2008 01/18/2008 APP LLH Public Works Review 01/18/2008 01/18/2008 WE LKW Public Works Review 01/28/2008 01/28/2008 APP LKW Plannin2 Review 01/18/2008 02/04/2008 APP T AJ Structural Review 01/18/2008 02/26/2008 APP DLM Pa2e 2 of3 Plot plan is not adequate. David discussed with applicant at the counter. On hold and waiting for new plot plan Storm water to existing drains for new addition Not considered an expansion of non-conforming use. No Planning issues. See documents for Plan review comments Status Issued CIIY OF SPRINGFIELD I Building/Combination Permit PERMIT NO: COM2008-00062 ISSUED: 03/1212008 APPLIED: 01115/2008 EXPIRES: 09/12/2008 VALUE: $ 18,900.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line To Request an inspection call the 24 hour recording at 726-3769. All inspections requested before 7:00 a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following work day. ReQuired Insnections I Footing: After trenches are excavated. Foundation: After forms are erected but prior to concrete placement. Post and Beam: Prior to floor insulation or decking. Floor Insulation: Prior to decking. Shear Wall Nailing: Before covering sheathing with finish materials. Framing Inspection: Prior to cover and after all rough in inspections have been approved. Wall Insulation: Prior to cover. Ceiling Insulation: Prior to cover. Final Building: After all required inspections have been requested and approved and the building is complete. Rough Mechanical: Prior to Cover Final Mechanical: When all mechanical work is complete. Rough Electric: Prior to Cover Final Electric: When all electrical work is complete. Underfloor Plumbing: Prior to insulation or decking. Underfloor Drain: Prior to cover or placement of concrete. Rough Plumbing: Prior to cover and including required testing. Final Plumbing: When 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 of 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. _ kA:7ovto ~-~ ~ Owner or Contractors Signat~ IJ/n'i 108 Date Pa2e 3 of3 ZON INITIALS DATE SOURCE 225 {ill' uI STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 . ELECTRICAL PERMIT APPLICATION City Job Number CtJJu 2LttJ~ -LJaah 2. 1. ~,,~ --w-,r- ,- ",~~~~- ~ ~i,-%&f:', 0 ~4N~~~>~~W''W'''_- ~ rpION/9F INSTALLATION: v ~~..m,,~MJ,..... M..W,~k,~ ~,~ },,, ,,~J.itWW[GfIDHiM+' ^ r~S'7 .c J/" LEGAL DESCRIPTION: 17tJZ 31/4 O.35tT1J JOB DESCRIPTION: , J4tAh (~ /!:, I~? ;1A/TfI Permits are non-transferable and expire if work is not started within 180 days of issuance or if work is Suspended for 180 days. flWIIIlII:~::- ""4I1l!ffi!I~' . ~q" T"Y%1lf :?'!I;'l;i;, ::7 - "'". "", ,?~: "' 2. "'CONTRA~~ ~R IN~T31J~'rf{01Y ONfll\,:; L_ ' ~ Awa~, "~ '"" Aik ,,,,,Wb,, ,'''''' ,*IIIIL. Electrical Contractor Address / City Expiration Date Signature of Supervising Electrician OwnersName JL/A-~JtlINd~ Address ,~~ 1!::. Sr~ City ~Ar/~Phone 726 "~l3-3 OWNER INSTALLATION The installation is being made on property I own which is not intended for sale, lease or rent. Ownti's Signature: )< ~'o/- ~ /7l --....." ., - / . Inspection Request: 726-3769 3-/2-- o~ Date 3. .'._,. - '.' ... ....... ". -~__w E,FEiJ;:scHifilf]iEfJJEuj , ~:,,,,"~.......-~,,~,4~,:~ Vv.v..-M&~.<~":~.. --.!_>__>&<;;:;&,0d'~: ~ ~ ~-;~;0+t ,~k P"*f1 umt,41i1 ,~1>$<"""",mN_fl,_ ----'i~ Service Included 1000 sq. ft. or less Each additional 500 sq ft. or portion thereof Each Manufact'd Home or Modular Dwelling ServIce or Feeder $117.00 $ 21.00 $55.00 200 Amps or less 201 Amps to 400 Amps 401 Amps to 600 Amps 60 I Amps to 1000 Amps Over 1000 AmpsN olts Reconnect Only $ 70 00 $ 83.00 $ 13 8 00 $180.00 $413,00 $ 55.00 f1ltl C. ;. ra" ., - "VI{ tU ~ Nottilcatlon Center. Those ruJes are set forth InstrJI~tA<<W':j~l!cferWtlb,n ff-flIettWPe AR 952-001- 2000\mm otdssllnay obtain copies of the n~bV> 201 A1n.p~ittgftl03JOO.t'ser. (Note: the teleEtw~~oo 401 ~~t>oor&HP.Pregol1 Utility l'lOllnC'\I~oo Center is 1-800-332-2344). Over 600 Amps or 1000 Volts see "B" above. D. ~ik : irc~its -- 1( """"- New Alteration or Extension Per Panel One Circuit I Each Additional Circuit or with I Service or Feeder Permit $ 48 00 ~ ~t!k!) $ 4.00 4- kJ -----:.-'> ,~~\i~y;nrrr>x> '< ,-'7:~,,*1 Yfq?~ --, ^"'^"<<'<'<'<''': E. '~"_~ ,~~U~"~~,~f,f~~~r;:~,~l~~~a..,,,,,n~, Pump or irrigation $ 55.00 Sign/Outline Lighting $ 55 00 Limited Energy/Residential $ 28.00 Limited Energy/Commercial $ 50.00 Minimum Electric Permit Inspection Fee is $50.00 + Surcharges f' ,-- - '<~ ~W~...,"":: <l;)Mn;<'i7;;~, t::n:mm'€k!i~ ,;~;,- ~"-'l04;~~;#,if; > lltn T@T:Al;,0E;A'80VEIlII'IIII""~,~c" " 11.U~ .w-.0%lfA%P'~4t&to:,4~~,~ ,":,'~~ '~lffiJ>wnl?\4t~,,::: C;-2-6-0 - 2.4' 0. r ~. 2..0 7.'V ~.~(- THIS 1j21ffi~~ ~"'Alt<tgEXPIRE IF THE WORK AUTHt9jlpl~~~H9trlS PERMIT IS NOT COMW~Mew~~eABANDOf\!ED FOR ANY H9rR~Y PERIOD Shared Dnve(T )/BuIidmg FonnsIElectncal PermIt Apphcatlon 1-08 doc Construction Contractors Board 700 Summer St NE Suite 300 PO Box 14140 Salem OR 97309-5052 Phone: 503-378-4621 Web Address: www.ccb.state.or.us Penmt#: Cdl#~~,-06k!J~2- 6 ST Date' 3 D ~ 1il.6 , I Address: --.3? s: Issued by{J!jcf\( ^ / Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4) requzres residentzal constructzon permzt applicants who are not licensed with the Construction Contractors Board to sign the following statement before a buildzng permit can be zssued. Thzs statement is required for reszdential building, electrical, mechanical and plumbing permits, Lzcensed architect and engzneer applicants, exempt from licensing under ORS 701.010(7), need not submit thzs statement. This statement will be filed with the permzt, Fill in the appropnate blanks and initial boxes 1 and 2, and either box 3A or 3B: %1. ~.2. I own, reside in, or will reside in the completed structure. I understand that I must become licensed as a construction contractor if the structure is sold or offered for sale before or on completion. o 3A. My general contractor is (Name) (CCB #) I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board, OR ~ 3B. I will be my own general contractor. IfI hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. IfI change my mind and hire a general contractor, I will contract with a contractor who is licensed WIth the CCB and will immediately notify the office issuing this building permit of the name of the contractor. I hereby certify that the above information is correct and that I have read and do understand the Information Notice to Property Owners about Construction Responsibilities on the reverse side of this form. Xk=~~~- - (Signatun/ofpermit applicant) (Date) (White copy to zssuing agency permit file, pznk copy to applzcant.) Property_owner. doc 06-01-04 Acting as Your Own ~eneral Contractor? INFORMA liON NOTICE TO 'PROPERTY OWNERS ABOUT CONSTRUCTION'RESPONSIBllITIES ., _?: -t ~ . ,. , . .., . NOTE: This Information Notice to Properly Owners about Construction Responsibilities was developed by the Construction Contractors Board in accordance with ORS 701 055(5), passed by the 1989 Oregon LegiS/atu~e'J f . ;'~- If you are acting as your own contl1lctor to construct a new home or make a substantIal rmprovement to an eXlstIng structure, you can prevent m;iny problems_by,befng aware of the follOWIng responsIbihtIes and concerns, ~mployer Responsibilitie~ :2'. .' . _ You wIll, m most instances, be ruled to be an "employer", a1!,d the cqptr.actors you contract wIth WIll be "employees" if you use contractors ,not h,c~~sed wIth tl:t~ Consy:uctIOn Co~tractors,'Board tO,do labor 1!l constructmg o,r to assist in the construchon or Improvemen~ of a re~IdentIal structure. As the efllployer, yon must comp~y with the fo~owing: , 1 J' ~ , ..... , I ~ ';:. . .. '" . .... -. - - Oregon's Withholding Tax Law: As an employer, you must withhold'Income taxes'from employee wages at the hme employees are paId. You wIll be hable for the tax payments even If you don't actuany wIthhold the tax from your employees. For more mformatIOn, call the Department of Revenue at 503-378-4988. " '" '. - Unemployment Insurance Tax: As an employer, you are reqUIred to'pay,a tax for unemployment insurance purposes on the wages of all employees. For more mformahon, call the Oregon Employment Department at 503-947-1488, .. , ~ _ .~" 2' , The Oregon BUSIness IdentificatIon Number (BIN) is a combIned ~umb~r for both Or.egon Wrthpoldmg arid Unemployment Insurance Tax. To file for a BIN, can 503-945-8091 or wwwdor state.or us/formsoav.htmll for the appropriate forms. '. .j , Workers' Compensation Insurance: As an employe(you' are subject to the Oregon Workers' Compensahon Law, and must obtaIn workers' compensatIon Insurance for your employees. If you f~ul to obtaIn workers' cvutpensatIon Insurance, you could be subJectto penaltIes and-be h~ble fdr all claIm co~ts Ifone ofymrr IVmpioyees is Injured on the .. ~.('"., -.... ~ ... " ~ Job. For more mformatIOn, call the Workers' Compensation DIVISIOn at the Department 'of-Consumer and BUSIness ServIces at 503-947-7815, U.S. Internal Revenue Service: As an employer, you must WIthhold federar'Income tax from employees' wages. You wIll be hablc for the tax payment even If you dIdn't actually WIthhold the tax. For a Federal EIN number, call the IRS at 1-800-829-4933 or-visit theIr web SIte at W\VV,r.,lfS.gOV:' - . t . ~ Other Responsibilities and Areas of Con~erns , . . Code Compliance: As the permIt holder for thIS proJect, you are responSIble for resolVIng any faIlure to meet code reqUIrements that may be brought to your attentIOn through Inspections. ~ . ~ ... ,~ - \ Liability and Property Damage Insurance: Contact yo~r msuranc'e agent to see 'If you have adequate' Insurance coverage for aCCIdents and omISSIOns such as falhng tools, pamt over spray, water damage from pipe punctures, fire or work that must be redone. Time: Make sure you have suffiCIent tIme to supervIse your employees:.~t- ,'1'< 'i~, " ~,~ !,~ Expertise: Make sure you have'the sIGlls to act as your' o~ general'co~ttictor: t6 coorClii-tate the work of rough-In and finish trades, and to notIfy bUIldIng offiCIals as the appropnate tImes so they can perform the reqUIred InSpectIons, If you have addItIonal questIOns call the ConstructIOn Contractors Board (503-378-4621) or wnte the agency at PO Box 14140, Salem, OR 97309-5052. ,fl Property-owner doc 06-01-04 CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT WORKSHEET JOURNAL OR JOB NUMBER C0M2008-00062 NAME OR COMPANY. Juan Dommguez LOCATION 3959 E Street TAX LOT NUMBER 1702311403500 DEVELOPMENT TYPE Smgle FamIly ResIdence NEW DWELLING UNITS 0 BUILDING SIZE (SF: 466 LOT SIZE (SF) 1 STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM IMPERVIOUS SF x I COST PER S F CHARGE 46600 I $0346 I = I $16125 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S F x COST PER S F I x DISCOUNT RATE I 0 00 $0 346 I 50% ITEM 1 TOTAL - STORM DRAINAGE SDC 2 SANITARY SEWER - CITY A REIMBURSEMENT COST. NUMBER OF DFU's x 7 B IMPROVEMENT COST NUMBER OF DFU's x 7 12632 r/J P-1 Q o U ~ P-1 f-< r/J >-< o ~ DISCOUNT $000 $161.25 $161.25 1070 COST PER DFU $26 83 $187.83 1091 COST PER DFU $20 40 $142.83 1092 = , ITEM 2 TOTAL - CITY SANITARY SEWER SDC 3 TRANSPORTATION A REIMBURSEMENT COST ADT TRIP RATE x 957 B IMPROVEMENT COST ADTTRlPRATE I x 957 I $330.66 I NUMBER OF UNITS x I I 0 I x INEWTRIPFACTOR' I 100 COST PER TRIP 2043 $0.00 1093 NUMBER OF UNITS x o ITEM 3 TOTAL - TRANSPORTATION SDC =, COST PER TRIP $90 10 $0.00 4 SANITARY SEWER. MWMC A REIMBURSEMENT COST INUMBER OF FEU's x I 0 B IMPROVEMENT COST NUMBER OF FEU's x o x NEW TRIP FACTOR 100 $0.00 1094 ICOST PER FEU , $95 35 $0.00 1054 = I COST PER FEU I $99039 = $0.00 I 1055 $0.00 1054 $0.00 1056 = , $0.00 - -,--,-~ = , $491.91 - _.r'_, - - ,.., CHARGE $24 60 2460 11079 $000 - --~- 1078 --- .... TOTAL SDC CHARGES = J $516.51 I MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL. MWMC SANITARY SEWER SDC SUBTOTAL (ADD ITEMS 1,2,3, & 4) 5 ADMINISTRATIVE FEE I SUBTOTAL x I ADM FEE RATE I $491 91 I 5% TOTAL SANITARY ADMINISTRATION FEE TOTAL TRANSPORTATION ADMINISTRATION FEE Kaye Wilson 1/28/2008 PREPARED BY DATE DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTIJRES x UNIT EQUIVALENT = DRAINAGE FIXTIJRE UNITS (NOTE FOR REMODELS, CALCULATE ONLY TIlE NET AuUII IONAL FIXTIJRES) NO OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUIVALENT UNITS IBATHTUB 1 0 3 = 3 I DRINKING FOUNTAIN 0 0 1 = 0 FLOOR DRAIN 0 0 3 = 0 INTERCEPTORS FOR GREASE I OIL / SOLIDS / ETC 0 0 3 = 0 INTERCEPTORS FOR SAND / AUTO WASH I ETC 0 0 6 = 0 LAUNDRY TUB 0 0 2 = 0 CLOTHESW ASHER I MOP SINK 0 0 3 = 0 ICLOTHESW ASHER - 3 OR MORE (EA) 0 0 6 = 0 IMOBILE HOME PARK TRAP (1 PER TRAILER) 0 0 12 = 0 /RECEPTOR FOR REFRIG / WATER STATION I ETC. 0 0 1 = 0 IRECEPTOR FOR COM SINK I DISHWASHER I ETC. 0 0 3 = 0 ISHOWER, SINGLE STALL 0 0 2 = 0 SHOWER, GANG (NUMBER OF HEADS) 0 0 2 = 0 SINK COMMERCIAL/RESIDENTIAL KITCHEN 0 0 3 = 0 SINK COMMERCIAL BAR 0 0 2 = 0 SINK WASH BASIN/DOUBLE LAVATORY 0 0 2 = 0 SINK SINGLE LA V ATORY/RESIDENTIAL BAR 1 0 1 = 1 URINAL, STALL / WALL 0 0 5 = 0 ITOILET, PUBLIC INSTALLATION 0 0 6 = 0 'TOILET, PRIVATE INSTALLATION 1 0 3 = 3 MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 7 *EDU (EQUivalent Dwellmg Umt) IS a dIscharge eqUivalent to a smgle family dwelhng Unit (20 DFU's) set at 167 gallons per day MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 CREDIT RATE/$I,OOO ASSESSED VALUE $529 $529 $519 $512 $4 98 $480 $4.63 $440 $407 $367 $322 $273 $225 $180 $159 $145 $1.25 $109 $092 $072 $048 $028 $009 $005 IS LAND ELGlBLE FOR ANNEXATION CREDI'f? (Enter 1 for Yes, 2 for No) IS IMPROVEMENT ELGIBLE FOR ANNEX CREDI'f? (Enter 1 for Yes, 2 for No) BASE YEAR 2 2 1979 CREDIT FOR LAND (IF APPLICABLE) VALUE / 1000 CREDIT RATE $0 00 x $5 29 =, $000 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALUE I 1000 CREDIT RATE $0 00 x $5 29 o TOTAL MWMC CREDIT $000 = 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone City of Springfield Official Receipt Development Services Department Public Works Department Job/Journal Number COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 COM2008-00062 Payments: Type of Payment Cash cRecemtl RECEIPT #: 2200800000000000319 Date: 03/12/2008 DescrIptIOn Fire SF Fee - Residential Storm Dramage ImpervIOus Area Samtary Sewer - Reimbursement Samtary Sewer - Improvement SDC SanItarylStorm Admm BUlldmg Permit FIxture Mlmmuml Adjustment Plumbmg Vent Fan Mlmmum/AdJustment MechanIcal ~Mechantcal Issuance Fee~ Add, Alter, Extend Clrc Add, Alter, Extend Clrc Ea Add + 5% Technology Fee + 12% State Surcharge + 10% Admmlstrattve Fee Paid By SANTANA DOMINGUEZ Item Total: Check Number AuthorIzatIOn Received By Batch Number Number How Received NJM In Person Payment Total: Page I of 1 1 :51 :41PM Amount Due 900 16 I 25 18783 ]4283 2460 195 86 4800 200 700 4300 2000 4800 400 1739 41 74 3569 $988.19 Amount Paid $988 19 $988.19 3/12/2008