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Home My WebLink AboutPermit Building 2008-3-20 CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2008-00361 ISSUED: 03/20/2008 APPLIED: 03/17/2008 EXPIRES: 09/2012008 VALUE: $ 221,916.00 Status Iss u ed 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 949 S 56TH ST ASSESSOR'S PARCEL NO.: 1802041108800 SPRINGFIETYPE OF WORK: Single Family Residence Residential TYPE OF USE: New PROJECT DESCRIPTION: Single family residence - Lauren Estates lot 2 Frontyard Setback: 20.00 \N~~lay Dist: Total: Side 1 Setback: 10.!!.Q. W,\,\t. c ~~~eet Trees Rqd: 2 Handicapped: Side 2 Setback: ,,~. \. 'C.~'6~W: t\~\\ \iJpaved Drive Rqd: Yes Compact: Rearyar~01A~~~\, S\\f>..\t\ \Wti.o?t ~t.D rCWhJ of Lot Coverage: 31.30 U\{es 'loU \~'l Solar set~~~.~;o.\l'C.\)\j~~ Ie, ~~Q,QDa _ ~l' /Ife90n ~~~~:~~e9~ne~;~~{\n f>..\.lO~~t.~\/c~ ?~t\\aD, I PUBLIC IMPROVEMENTS .ii~N ~\~~ adO?te1;~se tU~;~~ 952-U~ ~~ C -I9.\) D~ fo\\O'J-) \ cen\et. 0 \\ltou9 0\ \\le N\e e Street Impro)(~ents. F II I d "\O\i\lcSilfeQaJk"\~pt conIeS \eV"lbOn, t' u y mprove \" 952-IJ'V ~'ft;aln ...... \'rIe \8 ~\~,{~de 5' Storm Sewer Available: Yes \n O~~o~t~~!li~p\~\\\'\'l~'~nd Gutter Special Instruction: 0090\\'n9 \\le Ce Ote90n 332-2344). ca 'bet \ot \\l8.S ,,_eOO- {\urn cen\et \ Owner: DENNIS R MINIUM Address: 8745 THURSTON RD SPRINGFIELD OR 97478 I CONTRACTOR INFORMA TlON I Contractor Type General Contractor DENNIS R MINIUM License 62682 BUILDING INFORMATION. # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: 1 R-3 U VB # of Stories: 2 Height of Structure 28.00 Type of Heat: Forced Air Gas Water Type: Gas Range Type: Gas Energy Path: Path 1 Sprinkled Building n/a 4 I DEVELOPMENT INFORMATION I Notes: Stormwater to drain to weep hole in curb. I Valuation Description I Description Type of Construction $ Per Sq Ft or multiplier Square Footage or Bid Amount Pal!e 1 of 4 Phone Number: 541-954-3067 Phone Number: 541-747-8495 Expiration Date 12/11/2009 Phone 541-747-8495 Lot Size: Sq Ft 1st Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: 1,235 661 477 REQUIRED PARKING 2 Value Date Calculated Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line A.C. - Residen Dwellinl!s Dwellinl!s Garal!e Garal!e AC - Residential V Wood Frame V Wood Frame Garal!e Garal!e Fee Description Plan Review Residential -Mech Iss 2+ Appliances- + 10% Administrative Fee + 12% State Surcharge + 5% Technology Fee 3 Baths One & Two Family Addressing Assignment Appliance Vent Boiler/Comp Up To 100,000 btu Building Permit Curbcut Permit Dryer Vent Exhaust Hoods Fire SF Fee - Residential Furnace - up to 100,000 btu Gas Outlets 1-4 Plan Review Major - Planning Plan Review Residential Plan Review Residential PW Disc - 2nd Permit Residence Wiring 1000 Sq Ft Residence Wiring Ea Addtl 500 Sanitary Sewer - Improvement Sanitary Sewer - Reimbursement SDC MWMC Administration SDC MWMC Improvement SDC MWMC Reimbursement SDC Sanitary/Storm Admin SDC Transpo Improvement SDC Transpo Reimbursement SDC Transportation Admin Sidewalk Permit Storm Drainage Impervious Area Storm Sewer Each AddtllOO' Vent Fan Willamalane Single Family $5.00 $105.00 $105.00 $28.00 $28.00 Total Value of Project ~ Amount Paid $646.85 $40.00 $181.23 $203.23 $101.93 $337.00 $35.00 $7.00 $14.00 $1,059.60 $85.00 $7.00 $10.00 $118.65 $14.00 $5.00 $205.00 $20.94 $20.95 $-30.00 $117.00 $63.00 $632.53 $831.83 $10.00 $990.39 $95.35 $147.92 $862.25 $195.48 $70.58 $85.00 $752.25 $32.00 $28.00 $2,513.00 Date Paid 3/17/08 3/20/08 3/20/08 3/20/08 3/20/08 3/20/08 3/20/08 3/20/08 3/20/08 3/20/08 3120/08 3/20/08 3/20/08 3120/08 3/20/08 3120/08 3120/08 3/20/08 3120/08 3/20/08 3120/08 3120/08 3/20/08 3/20/08 3/20/08 3/20/08 3120/08 3/20/08 3/20/08 3/20/08 3/20/08 3/20/08 3120/08 3/20/08 3120/08 3/20/08 Pal!e 2 of 4 CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2008-00361 ISSUED: 03/20/2008 APPLIED: 03/17/2008 EXPIRES: 09/20/2008 VALUE: $ 221,916.00 1,896.00 60.00 1,836.00 400.00 77.00 $9,480.00 $6,300.00 $192,780.00 $11,200.00 $2,156.00 $221,916.00 03/19/2008 03/19/2008 03/17/2008 03/1712008 03/1912008 Receipt Number 1200800000000000235 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 1200800000000000263 Status Issued CITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2008-00361 ISSUED: 03/2012008 APPLIED: 03/17/2008 EXPIRES: 09/20/2008 VALUE: $ 221,916.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Total Amount Paid $10,508.96 Plan Reviews I Planninl! Review 03/17/2008 03/17/2008 APP TAJ Public Works Review 03/17/2008 03/17/2008 APP BRC SDC Worksheet Attached. BC Structural Review 03/19/2008 03/19/2008 ACC DLM See documents for Plan review comments 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. UleouiredJnsnections , Erosion/Grading Inspection: Prior to ground disturbance and after erosion measures are installed. Sidewalk - Curbside: After forms are erected but prior to placement of concrete. Curbcut - Standard: After forms are erected but prior to placement of concrete. Ufer Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing and/or foundation inspection. 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. Drywall: Prior to taping. Hold Downs Installed: Special Inspection performed prior to placement of concrete. Provide report to City Building Inspector. Final Building: After all required inspections have been requested and approved and the building 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. Shower Pan. Prior to covering and including required testing. Pal!e 3 of 4 CITY OF SPRINGFIELD Building/Combination Permit Status Issued PERMIT NO: COM2008-00361 ISSUED: 03/20/2008 APPLIED: 03/17/2008 EXPIRES: 09/20/2008 VALUE: $ 221,916.00 225 Fifth Street, Springfield, OR 541- 726-3 7 53 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Water Line: Prior to filling trench and including required testing. Sanitary Sewer Line: Prior to filling trench and including required testing. Storm Sewer Line: Prior to filling trench. Final Plumbing: When all plumbing work is complete. Underfloor Mechanical. Prior to insulation or decking and including required testing. Underfloor Gas: After line is installed and required testing and capped if not attached to an appliance. Rough Gas: After line is installed and required testing and capped if not attached to an appliance. Gas Service: After line is installed and line has been connected to a minimum of one appliance including required testing. Presure test done at this point. Rough Mechanical: Prior to Cover Final Gas: When all gas work is complete. Final Mechanical: When all mechanical work is complete. Rough Electric: Prior to Cover Electric Service: Approval required prior to utility company energizing service. Final Electric: When all electrical 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 d~con~tion. (q. - /~-- ?--- AC -C~- /~ Owner or Contractors Signature Date Pal!e 4 of 4 01/31/2008 09:55 7263676 CITY OF SPRINGFIELD PAGE 01 Dale 7..oN L-t.l {" INITIALS ---1J..M - ~ DATE -(ii1A.~JU'6 9.D" SOURCE ~'_ .(fJ~ as/do/OK , 225 FlFnf STJU;EY 0 SP~Gf1F.LD, OR ')7477 .. PH:(S4I)726-3753 e FAX: (541)726-36l19 ELEU;lJl(J[CALPERMlT APPUCATlON City Job Number ~~~ -- 863 C::,/ ~~~lmmJ~ .,..~' ~'~~JM~ 3. ,~IMI' ,~.. 1. ~~?W'ka:t:~~,<\PJI=- fJI\5~""~tiiIlJl~j~ ~:~"'''''''''"'''_'''''''''''.~lK~larl'''I>l''''rowc LEGAL DESCRIPTION: A_ I ~2- M / I C>~ ~ ~ Service Included JOB DESCRTPi'lON: JOOO sq. ft. or less r .. d~ ,A.4J ..;;z. , /!~ AL"..L Eac~ additional SOO sq. ft. or <;>.,. ~'/v~ $' W;~~ portlonthereof , I Pennits Illl'e 11I01lil-tnlll9fenble Bud ~irre 'fwork is Each Manufact'd Home or not sblrrted within 180 days of illSlIIsn~c OD' ihvork is Modulu Dwelltng Service OT Suspended for 18@ days. Feeder 2. r.1llI'i~~.Ji'l'O _ Ii' Electrical Contractor STEU E Ht::lUc/L Addres.<; P. O. E Ox 1- is fa I City GtEI Phone ~Jll- Ollo& S Supervisor License Number 351:r s Expindion Date J 0 - l - 0 q Const%'. Contr Number '41-~/8 Expiration Date t..j - .50 - 0 9 SIgna1l,lre of Supervising Electrician _J/;r;1~ . OwnernName ~~/S ML'J~ Ad~ss -874-5" 11kI"~J ~~ City ,)p~. _ Phone .7f7-il4JS OWNER INSTALLATION The installation is being made on property I own wblch is not intended for sale, lea.~e or rent. Owners Signature; .--- Inlipecdon Reque'll1:: 72603769 ~ $117.00 I/~#l> ~ t6-D .~ S 21 00 $55.00 B. c. 200 Amps or las $ 70.00 201 Amps to 400 Amps $ IB.OO 401 Ampsto6WUpsT!OiIJ G1l;'.J()n !-'." $138.00 ~ '\,\} to 601 Amps to fOOOlY\mpillc>;: Rduz)._JC' -', fr 5180:00 '" lJ lllty Over 1000 AMpWoJ~lon ConUr. It' i ,~,'~ 54'13.00' '. ';"'1 torth Reconnect oin)OAR 952-001-0u : U U IriJl,iS i55:00,1{ '!;!:J~.UU1" 0090. You may obtall-, cO~'les oftrle rules b .......~.uvt:"" S';,~lt\ .... n & lli'e~ I KBlIstallstiolll, AJtemtio~roiitWOO-332-2344). 200 Amps or less $ 55.00 201 Amps to 400 Amps $ 76.00 401 Amps to 600 Amps $110.00 E. Pump or Irrigation $ 55.00 Sign/Outline Lighting $ 5S.00 Limited EnergylResidentiaJ $ 28.00 Limited Energy/Commercial $ 50 00 Millimulb Electric Pennit Inspection !Fee is $50.00 + Surcbarges . J fb{) t1--c) -?/ "'0 ~I c.i. 0-0 .~~ 12% State Surcharge 10",4, Administrative Fee 5% Technology Fee . . TOTAl. -.2.2-~ ~ "D Shmt:d );)rJve(T )/I!UlldlJ1l1 FomWElcctttcal Pcnmt Applteation H)8~ _ __. ___ _._ _._ CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT WORKSHEET JOURNAL OR JOB NUMBER. C0M2008-00361 NAME OR COMPANY Dennis Mmmffi LOCATION. 949 56th Street TAX LOT NUMBER 18-02-04-11 08800 DEVELOPMENT TYPE. Smgle FamIly Residence NEW DWELLING UNITS 1 BUILDING SIZE (SF 2174 LOT SIZE (SF) 1 STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS SF x I COST PER S.F CHARGE I I 217400 $0346 = I $75225 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS IMPERVIOUS S F x COST PER S F x I DISCOUNT RATE I o 00 $0 346 I 50% = I ITEM 1 TOTAL - STORM DRAINAGE SDC I $752.25 5360 DISCOUNT $000 $752.25 2 SANITARY SEWER - CITY A. REIMBURSEMENT COST NUMBER OF DFU's I x 31 , B IMPROVEMENT COST NUMBER OF DFU's I x 31 I COST PER DFU $26 83 $831.83 COST PER DFU $20 40 $632.53 ITEM 2 TOTAL - CITY SANITARY SEWER SDC = , $1,464.36 rJ) ~ Q I~ IE-< /6 I~ I 1070 1091 1092 3 TRANSPORTATION A REIMBURSEMENT COST ADT TRIP RATE x I NUMBER OF UNITS I x COST PER TRIP x I NEW TRIP FACTOR 9.57 I 1 I 2043 I 100 $195.48 1093 B IMPROVEMENT COST I ADTTRIPRATE I x I NUMBER OF UNITS x I COST PER TRIP x I NEW TRIP FACTOR' I 957 , I 1 I $90 10 . I 100 $862.25 1094 ITEM 3 TOTAL - TRANSPORTATION SDC = , $1,057.73 4 SANITARY SEWER - MWMC A REIMBURSEMENT COST INUMBER OF FEU's x ICOST PER FEU I 1 , $95 35 =( , $95.35 1054 B IMPROVEMENT COST INUMBER OF FEU's x ICOST PER FEU I 1 I $990 39 ::: $990.39 1055 MWMC CREDIT IF APPLICABLE (SEE REVERSE) $0.00 1054 MWMC ADMINISTRATIVE FEE $10.00 1056 ITEM 4 TOTAL - MWMC SANITARY SEWER SDC = , $1,095.74 SUBTOTAL (ADD ITEMS 1,2,3, & 4) = I $4,370.08 5 ADMINISTRATIVE FEE SUBTOTAL x I ADM. FEE RATE CHARGE $4,37008 I 5% $218 50 TOTAL SANITARY ADMINISTRATION FEE 14792 1079 TOTAL TRANSPORTATION ADMINISTRATION FEE $70 58 1078 Billy Curtiss 3/17/2008 TOTAL SDC CHARGES =1 $4,588.58 PREPARED BY DATE DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVALENT = DRAINAGE FIXTURE UNITS (NOTE FOR REMODELS, CALCULATE ONLY THE NET ADDITIONAL FIXTURES) NO OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUIVALENT UNITS IBATHTUB 2 0 3 = 6 DRINKING FOUNTAIN 0 0 1 = 0 FLOOR DRAIN 0 0 3 = 0 INTERCEPTORS FOR GREASE / OIL / SOLIDS / ETC 0 0 3 = 0 INTERCEPTORS FOR SAND / AUTO WASH / ETC 0 0 6 = 0 LAUNDRY TUB 0 0 2 = 0 CLOTHESW ASHER / MOP SINK 1 0 3 = 3 CLOTHESW ASHER - 3 OR MORE (EA) 0 0 6 = 0 MOBILE HOME PARK TRAP (1 PER TRAILER) 0 0 12 = 0 RECEPTOR FOR REFRIG / WATER STATION / ETC 0 0 1 = 0 RECEPTOR FOR COM SINK / DISHWASHER / ETC 1 0 3 = 3 ISHOWER, SINGLE STALL 1 0 2 = 2 SHOWER, GANG (NUMBER OF HEADS) 0 0 2 = 0 SINK COMMERCIAL/RESIDENTIAL KITCHEN 1 0 3 = 3 SINK COMMERCIAL BAR 0 0 2 = 0 SINK WASH BASIN/DOUBLE LAVATORY 2 0 2 = 4 I SINK SINGLE LAVATORY /RESIDENTIAL BAR 1 0 1 = 1 URINAL, STALL / WALL 0 0 5 = 0 TOILET, PUBLIC INSTALLATION 0 0 6 = 0 ITOILET, PRIVATE INSTALLATION 3 0 3 = 9 MISCELLANEOUS DFU TYPE NUMBER OF EDD'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 31 *EDU (EqUIvalent Dwellmg Umt) IS a discharge eqUIvalent to a smgle famdy dwelh_~:~umtl~O ~~s) ~et at 167 gallons per day MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 CREDIT RATE/$I,OOO ASSESSED VALUE $529 $529 $519 $512 $498 $480 $463 $440 $407 $367 $322 $273 $225 $1.80 $159 $145 $125 $109 $092 $072 $048 $028 $009 $005 IS LAND ELGIBLE FOR ANNEXATION CREDIT? (Enter 1 for Yes, 2 for No) IS IMPROVEMENT ELGIBLE FOR ANNEX CREDIT? (Enter 1 for Yes, 2 for No) BASE YEAR CREDIT FOR LAND (IF APPLICABLE) VALUE / 1000 CREDIT RATE $0 00 x $5 29 = , CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALUE / 1000 CREDIT RATE $0 00 x $5 29 TOTAL MWMC CREDIT = 2 2 1979 $000 o $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 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-0036I COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-0036I COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 COM2008-00361 Payments: Type of Payment CredltCard cRecemtl RECEIPT #: 1200800000000000263 Date: 03/20/2008 DescriptIOn Plan Review Major - Plannmg Sidewalk PermIt Curbcut PermIt PW DISC - 2nd Permit Storm Dramage ImpervIous Area SanItary Sewer - ReImbursement SanItary Sewer - Improvement SDC Transpo ReImbursement SDC Transpo Improvement SDC MWMC Reimbursement SDC MWMC Improvement SDC MWMC AdmmlstratlOn SDC SanItary/Storm Admm SDC TransportatIOn Admm Plan ReVIew ResidentIal Buddmg Permit Addressmg ASSIgnment WllIamalane Smgle FamIly 3 Baths One & Two FamIly Storm Sewer Each Addtl 100' Furnace - up to 100,000 btu BOIler/Comp Up To 100,000 btu Vent Fan Apphance Vent Exhaust Hoods Dryer Vent Gas Outlets 1-4 -Mech Iss 2+ AppIiances- ResIdence WIrIng 1000 Sq Ft ResIdence WIrIng Ea Addtl 500 Fire SF Fee - ResIdential Plan ReView ResIdentIal + 5% Technology Fee + 12% State Surcharge + 10% AdministratIve Fee Paid By DENNIS MINIUM Item Total: Check Number AuthOrizatIOn Received By Batch Number Number How ReceIVed NJM 035512 In Person Payment Total: Page 1 of I 1 :55:07PM Amount Due 205 00 8500 8500 (30 00) 752 25 831 83 632 53 195 48 862 25 9535 99039 10 00 147 92 7058 2095 1,059 60 3500 2,513 00 33700 3200 1400 1400 2800 7.00 10 00 700 500 4000 11700 6300 118 65 2094 101.93 203 23 181 23 $9,862.11 Amount Paid $9,862 II $9,862.11 3/20/2008 tJ WilJamalane I",,, ., . ,..,. Park & RecreatIon Olstnct Job. No. ~ 2t)tJg - ~ 3'6/ SYSTEM DEVELOPMENT CHARGE WORKSHEET FOR 2007 NAME' 7)rv~J ~/dh PHONE: 74-7-~49S -. . ADDRESS:~ l~~ITY -f.t"/il STATE~ZIP:97-t7~ LOCATION OF PROPOSED BUILDING SITE: Street Address: 7'49 -S-~ 71 ~r ~ , Plat Name.).AUA!...6?U &//t;(L::CTax Lot Number:./ R~:L ot// ~B.1:>dtJ 1. DEVELOPMENT TYPE (Check appropnate dwelllng(s) Dwelling type definitIOns are on the back) A. Slnole-Famllv Detached NO. OF UNITS , 2-5" 13 6 ttJ X $~,J&3" per unit = $ 2-$ I J B Smole-Famllv Attached NO. OF UNITS X $2,426 per unit = $ C, Multl-Famllv Aoartment NO. OF UNITS X $2,032 per unit = $ D. Slnole Room Occuoancv NO OF UNITS X $1,016 per unit = $ E, Accessorv Dwellino Unit NO OF UNITS X $1,151.50 per unit = $ WILLAMALANE SDC $ 2. SDC CREDIT (If applicable) SDC payer must furnish proof of Wlllamalane Credit approval) $ ( 3. TOTAL WILLAMALANE NET SDC ASSESSED (If S:ZC r~duced for cre~lt) 1ft fJLd(:lYiLu ~p~e~rvices Department f S nngfiE Id J $ 2'5/3 ()$ / ;)0/ {Jr Date 5