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Home My WebLink AboutPermit Building 2003-6-30 . CITY OF SPRlI~ljnJ<..LU Building/Combination Permit PERMIT NO: cOM2003-00366 ISSUED: 06/30/2003 APPLIED: 05/13/2003 EXPIRES: 12/30/2003 VALUE: $ 135,252.00 -. Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 6754 Jacob Lane ASSESSOR'S PARCEL NO.: 1702341109300 Springfield TYPE OF WORK: Single Family Residence ,:;,'\9 REQUIRED PARKING ,0 .~""~., Floodpl'!:\n"> v'<:' ,cTo~l: 2 ,..-$0' 20'" rs:,' Handicapped: 03'" ')~} -, q'- 'G > ~' Cy .<.,0 0,0 Compact: {o e ..~sJ ': <{.... \,,~..... 0 % of Lot Coverage: ,F' ,\~' 12;OO~~ ",0<" ",0"'. ~'" ~ 'O~ ' ~ '...' 0'- ~v ,-' 0 c5' 1''''' o'V ~e,-"v'/j '\..~ 1,'\.eJ ..(,<,0 J{'\:". ..-,~ _ ,0 >t"~ I PUBLIC IMPROVEMENTSI~e'~,\\J.:~ C,o~~0~~'~";,f" \" <,,\)' v ~;::3 ';.....,'\. \.....'0 ,\~ fl; F II I d " \ 0" ~\) dildewalk,Typef!; u V mnrove " ~'V'''' ').: ,\ '$>" ~"cv~~ No ,0",,~J.. ~)") )<.,"~ c.D~wn's~outSlDrains: '0"" '....:'ll.. . a' ,....C ,....,.. '\~..., . "~ 0\ -...... ~~.. '\.::- o{-;J '\0 s::>C1l;:). ~,<:-r::l \\0\ ~e' \j <.l' ~C;?, ,:;,~ '" TYPE OF USE: PROJECT DESCRIPTION: SFR Owner: DENNIS R MINIUM Address: 8745 THURSTON RD SPRINGFIELD OR 97478 I CONTRACTOR INFORMATION I Contractor Type General Electrical Owner Plumbing Contractor DENNIS R MINIUM STEVE HAUCK DENNIS MINIUM DON CLEWIS License 62682 147618 62682 3307~ BUILDING INFORMA NON 'I~' 1 III ~ " ~ ,~ ~ 1 # of Stories: ~~ ~~ \\S 2 R-3 Height of~t'fu~t.rr~ ~yS> 30.00 V-I Type.. of)Iea(:~.) ~~orced Air Gas VN . lX..al'er~~: ,,?-CQ"f. Gas ~\lV~~Ra~~Yl!~ ~. Gas 4~~ '2J <xV'; ~~er~<P).tltl.S:S Path 1 '\~ ~\S ~""Y; c\. <xv \'''' . "V'; 0.~ ....... ...", ":' \ I DENEt:9PMENT INFORMATION I '/',. Overlay Dist: # Street Trees Rqd: Paved Drive Rqd: # of Buildings: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: SETBACKS Frontyard Setback: Side 1 Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: 16.00 11.00 5.00 97.00 109.00 Street Improvements: Storm Sewer Available: Special Instruction: Notes: Paee 1 of 4 New Residential Phone Number: 541-747-8495 Expiration Date 12/11/2003 04/30/2005 1211112003 06110/2005 Phone 541-747-8495 541-221-2665 541-747-8495 541-688-1931 Lot Size: Sq Ft 1st Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Impervious Surface Area: 10,500 830 874 415 Curbside 5' Curb and Gutter Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Description Tvne of Construction Dwellines Garaee V Wood Frame Garaee Fee Description + 10% Administrative Fee + 7% State Surcharge Plan Review Residential Temp Power 200 amps or less -Mechanical Issuance Fee- + 10% Administrative Fee + 7% State Surcharge 3 Baths One & Two Family Addressing Assignment Annexed 2000 Appliance Vent Building Permit Curbcut Permit Dryer Vent Exhaust Hoods Gas Outlets 1-4 Plan Review - Planning PW Mult 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 ,SanitarylStorm Admin SDC Transpo Admin SDC Transpo Improvement SDC Transpo Reimbursement Sidewalk Permit Storm Drainage Impervious Area Vent Fan WilIamalane Single Family Total Amount Paid . I Valuation Descrintion I $ Per Sq Ft or multiplier $74.60 $19.60 Square Footage or Bid Amount 1,704.00 415.00 Total Value of Project Fppc, PIilLI Amount Paid $5.00 $3.50 $443.72 $50.00 $10.00 $119.47 $83.63 $306.00 $8.00 $-1.40 $6.00 $682.65 $75.00 $6.00 $9.00 $4.00 $59.00 $-30.00 $106.00 $57.00 $436.54 $574.34 $10.00 $34.83 $332.86 $89.42 $50.31 $709.81 $160.87 $75.00 $536.79 $18.00 $1,000.00 $6,031.34 Date Paid 5/13/03 5/13/03 5/13/03 5/13103 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 6/30/03 Paee 2 of4 . CITY VI' ~rK11'lul'1ELD Building/Combination Permit PERMIT NO: cOM2003-00366 ISSUED: 06/30/2003 APPLIED: 05/13/2003 EXPIRES: 12/30/2003 VALUE: $ 135,252.00 Value Date Calculated $127,118.40 $8,134.00 $135,252.40 05/13/2003 05/13/2003 Receipt Number 1200200000000001179 1200200000000001179 1200200000000001179 1200200000000001179 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 1200200000000001673 . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: cOM2003-00366 ISSUED: 06/30/2003 APPLIED: 05/13/2003 EXPIRES: 12/30/2003 VALUE: $ 135,252.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Initial Review Plannine Review 05/14/2003 05/1512003 I Plan Reviews I 05/15/2003 APP 06/2712003 APP LLH EMM Planning information approved per revised plot plan. Waiting completion and as built of first tier wall. Passed to Engineering to review. Approved per Jim Donovan. All conditions of recorded Easement document and Stipulated Judgement of Dismissal apply. Public Works has called for a survey of easements for siting of the house. Ken Vogeney approved final review for Public Works. Public Works Review 06/20/2003 06/25/2003 APP DJW Structural Review 05/1512003 06/1212003 APP DLM To Request an inspection call the 24 hour recording at 726-3769. All inspection 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. L...iIir.lirlP1rI ~ 1 Temporary Electric: Approval required prior to Utility Company energizing pole. 2 Site InspeCtion: To be made after excavation but prior to setting forms. 3 Ufer Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing and/or foundation inspection. 4 Footing: After trenches are excavated. 5 Foundation: After forms are erected but prior to concrete placement. 6 Post and Beam: Prior to Door insulation or decking. 7 Floor Insulation: Prior to decking. 8 Shear Wall Nailing: Before covering sheathing with finish materials. 9 Framing Inspection: Prior to cover and after all rough in inspections have been approved. 10 Wall Insulation: Prior to cover. 11 Ceiling Insulation: Prior to cover. 12 Drywall: Prior to taping. 13 Hold Downs Installed: Special Inspection performed prior to placement of concrete. Provide report to City Building Inspector. 14 Final Building: After all required inspections have been requested and approved and the building is complete. 15 UnderOoor Plumbing: Prior to insulation or decking. 16 UnderOoor Drain: Prior to cover or placement of concrete. 17 Rough Plumbing: Prior to cover and including required testing. 18 Water Line: Prior to filling trench and Including required testing. 19 Sanitary Sewer Line: Prior to filling trench and including required testing. 20 Storm Sewer Line: Prior to filling trench. 21 Final Plumbing: When all plumbing work is complete. 22 UnderOoor Mechanical. Prior to insulation or decking and including required testing. 23 Rough Gas: After line is installed and required testing and capped if not attached to an appliance. Palle 3 of 4 . . CITY OF SPRINGFIELD Building/Combination Per'mit PERMIT NO: cOM2003-00366 ISSUED: 06/30/2003 APPLIED: 05/13/2003 EXPIRES: 12/30/2003 . VALUE: $ 135,252.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line 24 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. 25 Rough Mechanical: Prior to Cover 26 Final Gas: When all gas work is complete. 27 Final Mechanical: When all mechanical work is complete. 28 Rough Electric: Prior to Cover 29 Electric Service: Approval required prior to utility company energizing service. 30 Final Electric: When all electrical work is complete. 31 Sidewalk - Curbside: After forms are erected but prior to placement of concrete. 32 Curbcut - Standard: After forms are erected but prior to placement of concrete. 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 ti~~)ns:ru~ '~--='- c;:::" -;3C7 ,-~ -~ . Owner or Contractors Signature Date Paee 4 of 4 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number C0M2003-00366 COM2003-00366 COM2003-00366 C0M2003-00366 C0M2003-00366 COM2003-00366 COM2003-00366 C0M2003-00366 COM2003-00366 COM2003-00366 C0M2003-00366 COM2003-00366 COM2003-00366 C0M2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 C0M2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 COM2003-00366 Payments: Type of Payment Check "'~"".c.''''''' WIt, ,.."'..".""..~ ....,'.~..,.i ." " . ..... ,I . ... \ ..,.-......_,..,-,._ 0" ...,.... Receipt #: 1200200000000001673 Description Addressing Assignment Willamalane Single Family Residence Wiring 1000 Sq Ft Residence Wiring Ea Addtl 500 Building Permit 3 Baths One & Two Family Vent Fan Exhaust Hoods Appliance Vent Dryer Vent Gas Outlets 1-4 -Mechanical Issuance Fee- + 7% State Surcharge + 10% Administrative Fee Plan Review - Planning Sidewalk Permit Curbcut Permit PW Mult Disc - 2nd Permit Storm Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Transpo Reimbursement SDC Transpo Improvement SDC MWMC Reimbursement SDC MWMC Improvement SDC MWMC Administration SDC SanitarylStorm Admin SDC Transpo Admin Annexed 2000 Paid By DENNIS MINIUM Received By djb l.;heck Number Batch Number Authorization Number City of Springfield Official Receipt Development Services Department Public Works Department Date: 06/30/2003 12:01 :20PM' Amount Paid Item Total: 8.00 1,000.00 106.00 57.00 682.65 306.00 18.00 9.00 6.00 6.00 4.00 10,00 83.63 119.47 59.00 75.00 75.00 (30.00) 536.79 574.34 436.54 160.87 709.81 332.86 34.83 10.00 89.42 50.31 (1.40) $5,529.12 . . How Received In Person Payment Total: Amount Paid $5,529.12 $5,529.12 .... 225 5" STREET, SPRINGFIELD. OR 97477 (541)726.3753 FAX(541) 726-3676 Estimated Base Flood Elevation & Disclaimer For property located at b 7 SY 1Ae:..oB LANE , Springfield OR The calculated Base Flood Elevation (BFE) for lot# bO , Levi Landing - Second Addition is 5 J I. 6 feet above mean sea level, based on the current FEMA datum information. The floor level of the residence to be placed on the lot must be certified at least one foot above the Base Flood Elevation as indicated above. (Please note - the City's surveyed benchmark datum information and the FEMA benchmark datum are not the same for this area. Add O.30ft to the City's benchmarks to adjust to the FEMA benchmark elevations, ) The estimated base flood elevations in this area are based on interpretation of scientific and engineering evaluations known to the city at this time. Larger floods can and will occur on rare occasions. Flood heights may be increased by human-made or natural causes, The City's estimation of a base flood elevation does not imply that land within this area will be free from flooding or flood damages or that conformance with the requirements of the City will protect the property fromjlooding or flood damages. The City, its officers, agents and employees shall not be liable for any flood damage that may result from estimation of base flood elevation or any other administrative decision made regarding administration of the City's Floodplain Development Code. The developer of this propertY may elect to perform additional scientific and engineering studies for consideration by the City to further refine the estimated base flood elevation for this property. The developer of this property may also elect to undertake additional development and construction measures in addition to those required in article 27 of the Springfield Development Code designed to avoid or -minimize the potential for flood hazards and damage. Such additional measures are subject to City approval. :Acknowledgment: I hereby acknowledge receipt of a copy of this document: Name (print):;] " . . t"~, Slgnatur~ ~. - ., Date (This copy to be slgneaby Owners authorized agent and retamed m City address file) CITY OF JtINGFIELD SYSTEMS DEVELOPMEAoRKSHEET .JOURN~L OR JOB NUMBER: COM2003-00366 NAME OR COMPANY: Dennis Minium LOCATION: 6754 Jacob Lane TAX LOT NUMBER: 17023411 TL09300 DEVELOPMENT TYPE: NEW DWELLING UNITS BUILDING SIZE (SF) 0 LOT SIZE (SF): I. SmRM DRAINAGE DIRECf RUNOFF TO CITY STORM SYSTEM , IMPERVIOUS S,F. ,I COST PER S,F. CHARGE I '1903.50 I $0.282 , = , $536.79 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCfED TO CITY STANDARDS I IMPERVIOUS S,F, I ,I COST PER S.F. ,,' DISCOUNT RATE I ' DISCOUNT 0.00 I I $0.282 " 50% = , $0.00 ITEM 1 TOTAL - STORM DRAINAGE SDC $536.79 I 2"SANITARY SEWER - CITY A. REIMBURSEMENT COST: , NUMBER OF DFU's I ,I COST PER DFU I 26 I' $22.09 B. IMPROVEMENT COST: , NUMBER OF DFU's I ' I 26 I COST PER DFU $16,79 ITEM 2 TOTAL - CITY SANITARY SEWER SDC = I $1,010.88 3. TRANSPORTATION A. REIMBURSEMENT COST: I ADTTRIP RATE I , I NUMBER OF UNITS I I 9.57 'I I B. IMPROVEMENT COST: I ADTTRIPRATE , x I NUMBERIOFUNITSI i 9.57 I ITEM 3 TOTAL - TRANSPORTATION SDC x I COST PER TRIP , I NEW TRIP FAcroRI I $16.81 , 1.00 = x , COST PER TRIP , I NEW TRIP FAcroRI , $74.17 I 1.00 = = , $870.68 10455 $536.79 = $574.34 en W Cl o U ~ ~ en G W ~ 1070 11091 I 11092 I I II 1093 1094 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: 'NUMBER OF FEU's I x ICOST PER FEU , I . I $332.86 B.IMPROVEMENTCOST: 'NUMBER OF FEU's I x ICOST PER FEU 'I $34.83 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM4TOTAL-MWMCSANITARYSEWERSDC = , SUBTOTAL (ADD ITEMS 1,2,3, & 4) = , 5. ADMINISTRATIVE FEE: 'SUBTOTAL 1 x I ADM. FEE RATE 1= I I $2,794,64 , 5% TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: - - D.Wright PREPARED BV 6/23/2003 DATE = $436.54 $160.87 $709.81 . ~ DRAINAGE FIXTURE UNI~(DFU) CALCULATION TABLE NUMBER OF NEW AXTURES x UNIT EQUIVALENT = DRAINAGE AXTURE UNITS (NOTE: RJR REMODEL5, CALCULATE ONLY THE NET ADDITIONAL FIXTURES) NO. OF FIXTURES UNIT FIXTURE TYPE r NEW OLD EQUIVALENT BATHTUB 2 0 3 = DRINKING FOUNTAIN 0 0 1 = FLOOR DRAIN 0 0 3 = INTERCEPTORS FOR GREASE lOlL 1 SOLIDS 1 ETC. 0 0 3 = INTERCEPTORS FOR SAND 1 AUTO WASH 1 ETC. 0 0 6 = LAUNDRY TUB 0 0 2 = CLOTHESW ASHER 1 MOP SINK 1 0 3 = CLOTHESW ASHER - 3 OR MORE (EA) 0 0 6 = MOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = RECEPTOR FOR REFRIG 1 WATER STATION I ETC. 0 0 1 = RECEPTOR FOR COM, SINK 1 DISHWASHER 1 ETC, I 0 0 3 = SHOWER. SINGLE STALL 1 0 2 = ISHOWER. GANG (NUMBER OF HEADS) 0 0 2 = ISINK: COMMERCIAURESIDENTIAL KITCHEN 1 0 3 = ISINK: COMMERCIAL BAR 0 0 2 = ISINK: WASH BASIN/DOUBLE LA V ATORY 0 0 2 = ISINK: SINGLE LA V ATORY/RESIDENTIAL BAR 3 0 1 = IURINAL. STALL! WALL 0 0 5 = ITOILET. PUBLIC INSTALLATION 0 0 6 = ITOILET. PRIVATE INSTALLATION 3 0 3 = MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = TOTALDRAmAGEFDnTIREUNITS DRAINAGE FIXTURE UNITS 6 o o o o o 3 o o o o 2 o 3 o o 3 o o 9 o 26 "'EDU (Equivnlenl DwellinJ!; Unit) is a dischaflt( equivalent to a single family dwellinl? unit (20 DFU's) set at 167 23l1ons per day MWMC CREDIT CALCULA nON TABLE: BASED ON COUNTY ASSESSED VALUE YEAR CREDIT RA TEI$I.ooo I ANNEXED ASSESSED VALUE IS LAND ELGIBLE FOR ANNEXATION CREDIT? BEroRE 1979 $4.92 (Enter 1 for Yes. 2 for No) II 1979 $4.92 IS IMPROVEMENT ELGIBLE FOR ANNEX, CREDIT? 0 1980 $4.83 (Enter I for Yes. 2 for No) I 1981 $4.77 BASE YEAR 2000 1982 $4.64 1983 $4,47 CREDIT FOR LAND (IF APPLICABLE) 1984 $4.30 VALUE 1 1000 CREDIT RATE 1985 $4.09 $35.01 x $0.04 = , $1.40 1986 $3.78 1987 $3.41 CREDIT FOR IMPROVEMENT (IF AFfER ANNEXATION) 1988 $2.98 VALUE 1 1000 CREDIT RATE 1989 $2.52 $0.00 x $0.04 = 0 1990 $2.06 i 1991 $1.64 I 1992 $1.45 I TOTAL MWMC CREDIT = $1.40 1993 $1.31 I 1994 $1.13 I 1995 $0.97 I 1996 $0.82 1997 $0.63 1998 $0.41 t999 $0.22 L- 2000 $0.04 1ft"-- \0\\0 0 '~~/ . 2!SFIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)72~-.J68(_:, ~:':' \ ~ ~ ~ ELECTRIC PERMIT APPLICATION \o\\C"",~ "."e. )..,'\~_ ./' '^ e ""," ./ --- . City Job Number . W Date -(<' ,^",<, 1>' f< ./ /./ 1-~("IQ\o'" ~O\,\\\ /" '/ I 3. I COMPLETE FEE SCm,'D~E.~v \0 . "O\~JII Q" . '1-06 ...0\\ A. I New Residential- Singl~"~r Multi-Family per dwelling unit. ' I ( I 0 CITY OF S,>:-~<INGFIELD, OREGON 200 Amps or less 20 I Amps to 409-Amps 40 I Amps to 600 Amps 60 b Amps to 1000 Amps .,'. ...' .,(Over-\OOO AmpsNolts ~ I . \~... -",. ,,?> ,.Reconnect Only ~..... 0..... ......... ~\,) ..00:;, \'?;(;$-.'\.(>_Cj~(J'. ,'c'. , 3S=rT 5, ,i}-lI,y,1O O~,,'.c;J Temporary Sm'ices or Feeders "V' '0'\' ,v 0'.:<\' .~O', C)\' ,0'" 0 S0 0~ "" -~ oN> I () - 4 - 0<1 .;Y ",e -<,<,0 .0\:1: ,r"lnst!!lla~~in, Alteration or Relocation ,\..J>c}O~ ~0;' ~~'~"GO~'" '2obAJil~s\or less /1I~ "! C)'J \" &)' ,,' :;.0' ""~ (," Constr, Contr. Number ..., T'l:1,O'/'I~,,"'" ,,~'. ~'\.'J ,10~:\~ps to 400 Amps 4 't. :,Q" ,,0 ,/:\5 ,\ 0'" :;.0" ~o0.- 40 VAmps to 600 Amps Expiration Date - 50 - 0)$, 'v~ uf-' ,'01;' e'" 0'(>, ," ~u" ,",' . '()~ ../. ',' .,r Over'600 Amps or 1000 Volts see "B" above. Signature of Supervising Electri~ian \.)~ ~~. ~~~~ 0~ t<'$'~:<-: D. I Branch ~'i..cuits_ ; '_;,-->t::'-~;-,:M~:'- . ,;::i' *'"' d" ,,('~ ~iJ" .., C /J _ J Ll G ,>i-O C;' New Alteration or Extension Per P~~ ~\;) \ Z",f;f(cUA- '" One Circuit ~~ ,,;; ,~\\ 's.~ 43.00 " Each Additional Circuit o\.~dlS ~'i:.'(\'S:.\) '(v' "-- -1\i' c.. N\". ~\\ \."'" Service or Feeder ProQU-- \y.,~ SJ'~ $ 3.00 Owners Name LJU \ .~ ,,\U, II \ ,1'1(;. .,'5- '0'(\ ,0Y~ "t>..~ - 1f2." ^ ~ ,..1\ . I ",,\\;..<'.~,,,.'~~,,,,, ,c.t''' C I Address L)' I""'t ~ ~.Lf1.~ ~ Q( k' E. \l'illi,~~~O\'i')IP<~OIle~e.r not inct"~ed) -Each Installation ~ w-W-0 ~~ City 'QC"ar() Phone \'\1.?Ms pumP;l>t\~~ ~v $ 50.00 \ \'......... SignloWh~~ill\l~g $ 50.00 Limited ~rgylResidential $ 25.00 Limited Energy/Commercial $ 45.00 I. I LOCA11ON OF INSTALLATION \ Q'\ ~ _\c\'t cl:'\ ~C7 . LEGAL DESCRIPTION \<"\rQ.,~\ \ rA.~ JOB DESCRlPTlON_ ~I \q ~ ~ ",-c.a~ Permits ~e non-transferable expire if work is not started within 180 days of issuance or if work is Suspended for 180 days. 2. I, CONTRACTOR INSTALLATION ON:Ltij SlEUE f/(Juct Electrical Contractor Address W-8 51 'I" .Jj, .s City <;;fr;~,"cIJ " '"" ~I- ~"S Phone Supervisor License Number Expiration Date OWNER INST ALLA TION The installation is being made on property I own which is not intended for sale, ~ease or rent. Owners Signature: Inspection Request: 726-3769 Service Included 1000 sq, ft, or less Each additional 500 sq, ft, or portion thereof $106.00 \D\n.OO 5f) ,en \ .3 $ 19.00 Each Manufact'd Home or Modular Dwelling Service or Feeder $50.00 B.l. Services or .Feeders - Tllstanati~~,i~lte~ati,oris orR;~loc~tion: $ 63.00 $ 75.00 $125.00 $163.00 $375.00 $ 50.00 \ . I ~ 5./3fB $ 50.00 _ ~cV $ 69.00 $100.00 .1 7% State Surcharge 10% Administrative Fee Minimum Electric Permit Inspection F + Surcharges TOTAL Shared Drive(T:)lBuilding Fo