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Home My WebLink AboutPermit Building 2003-10-7 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: COM2003-00839 ISSUED: 10/07/2003 APPLIED: 08/28/2003 EXPIRES: 04/07/2004 VALUE: \ $ 175,410.00 SITE ADDRESS: 6680 Jacob Ln ASSESSOR'S PARCEL NO.: 1702341109800 Springfield TYPE OF WORK: Single Family Residence TYPE OF USE: PROJECT DESCRIPTION: SFR - same as 6772 Jacob Ln COM2003-00367 New Residential Owner: DENNIS R MINIUM Address: 8745 THURSTON RD SPRINGFIELD OR 97478 Phone Number: 541-747-8495 I CONTRACTOR INFORMATION ~~ Contractor \1-m~-; ~Q\;xpiration Date DENNIS R MINIUM \.i-'?\"'\~~8'i <.,Q'" 12/1I/2003 STEVE HAUCK ~ ~t-\..\.. ,'(.f.;, HJ.618 04/30/2005 MARSHALLS ~~\\:; \.~~\\ 'O'U~~\.'" t-'Ot-~\1's790 12/23/2003 DON CLEWIS -<1,.\\'21 '? _o\1.~~ _ (\~ \'21 _" 33076 06/10/2005 .- t:'~! .._," 1\.1;' ~BtiILDINGJNfuRMA TION I ",JJ 'C\l ~ t-~'{#\f Stories: 2 Lot Size: Height of Structure 30.00 Sq Ft 1st Floor: Type of Heat: Forced Air Gas Sq Ft 2n~lFloor: Water Type: Gas s~.gtl~~~n!: Range Type: Gas ~eo.\S'I.mIG.l~~~lSarport Energy Path: ~a.tb'" e CSq'Fi~'if;oO. O~e~O... '0'1 \~ \}~.reo;lofit~!!5face Area: r:'" .!"OU _n.( n~' f'\\:" I DEVELOPMEN'I-'NF~~~'fION 'f~~~O\}~~~ 0\ \;e9~0'~\0{\ l"" I'l'l'v G'" .oQ\~ c09'>1.\~0\"'.8A'QIo;kED PARKING ~\O '!..,O{\ .00" ~&){\ 0\0' ~ ~u~: Overlay D~\C0' S"t :i 0'0 ~. ~ V~\'( ~\I: 2 # Street~~~~b,} ~'8 C0{\\0 ~09JfY1., !\ ~'?>'2:'2:'Handicapped: Paved Drive ~";I. ^\~0 .~eO "Af;)f;)o Compact: Ci ~\~'yJ \Op" \'5 -Yes % of Lot CovefJi;';.~0~ 0{\\0~ 11.00 ;.~ (j Contractor Type General Electrical Mechanical Plumbing # of Buildings: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: SETBACKS Front yard Setbaek: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Improvements: Storm Sewer Available: Special Instruction: Notes: 19.00 7.00 29.00 89.00 104.00 Phone 541-747-8495 541-221-2665 541-747-7445 541-688-1931 1 R-3 U-l VN 10,803 740 1,070 480 3 I PUBLIC IMPROVEMENTS I Sidewalk Type: DownspoutslDrains: FullV Improved Yes Curbside 5' Curh and Gutter Page I of4 . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2003-00839 ISSUED: 10/07/2003 APPLIED: 08/28/2003 EXPIRES: 04/07/2004 VALUE: $ 175,410.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726.3769 Inspection Line I Valuation Descrintion J V Wood Frame Gara2e $ Per Sq Ft or multiplier $90.60 $23.80 Square Footage or Bid Amount 1,810.00 480.00 Value Date Calculated Description DwelIin2s Gara2e Tvpe of Construction Total Value of Project $ I 63,986.00 $11,424.00 $175,410.00 08/28/2003 08/28/2003 ~ Fee Description Amount Paid Date Paid Receipt Number Plan RevIew Same As $100.00 8/28/03 1200200000000002035 -Mechanical Issuance Fee- $10.00 10/7/03 1200200000000002283 + 10% Administrative Fee $138.67 10/7/03 1200200000000002283 + 70/0 State Surcharge $97.07 10/7/03 1200200000000002283 3 Baths One & Two Family $306.00 10/7/03 1200200000000002283 Addressing Assignment $8.00 10/7/03 1200200000000002283 Annexed 2000 $-1.41 10/7/03 1200200000000002283 Applianee Vent $6.00 10/7/03 1200200000000002283 Building Permit $812.65 10/7/03 1200200000000002283 Curbcut Permit $75.00 10/7/03 1200200000000002283 Dryer Vent $6.00 10/7/03 1200200000000002283 Exhaust Hoods $9.00 10/7/03 1200200000000002283 Furnace - up to 100,000 btu $12.00 10/7/03 1200200000000002283 Gas Outlets 1-4 $4.00 10/7/03 1200200000000002283 PW Mult Disc - 2nd Permit $-30.00 10/7/03 1200200000000002283 Residence Wiring 1000 Sq Ft $106.00 10/7/03 1200200000000002283 Residence Wiring Ea AddU 500 $57.00 10/7/03 1200200000000002283 Sanitary Sewer - Improvement $430.25 10/7/03 1200200000000002283 Sanitary Sewer - Reimbursement $566.00 10/7/03 1200200000000002283 SDC MWMC Administration $10.00 10/7/03 1200200000000002283 SDC MWMC Improvement $34.83 10/7/03 1200200000000002283 SDC MWMC Reimbursement $332.86 10/7/03 1200200000000002283 SDC Sanitary/Storm Admin $88.50 10/7/03 1200200000000002283 SDC Transpo Admin $51.54 10/7/03 1200200000000002283 SDC Transpo Improvement $727.42 10/7/03 1200200000000002283 SDC Transpo Reimbursement $164.89 10/7/03 1200200000000002283 Sidewalk Permit $75.00 10/7/03 1200200000000002283 Storm Drainage Impervious Area $535.99 10/7/03 1200200000000002283 Temp Power 200 amps or less $50.00 10/7/03 1200200000000002283 Vent Fan $18.00 10/7/03 1200200000000002283 Willamalane Single Family $ I ,000.00 10/7/03 1200200000000002283 Total Amount Paid $5,801.26 Pa2e 2 of4 . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2003-00839 ISSUED: 10/07/2003 APPLIED: 08/28/2003 EXPIRES: 04/07/2004 VALUE: $ 175,410.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Initial Review Plannin!! Review 08/29/2003 08/29/2003 I Plan Reviews I 08/29/2003 APP 09/08/2003 APP LLH EMM Puhlie Works Review 08/29/2003 09/09/2003 WI MS 5' easement and no huild line criteria apply. See enclosed Judgement and easement documents. Building may not exceed 30' in height. 9/24/03 - Contacted applicant and'he informed me he plans to take storm drainage to the street for this lot. Ken Vogeney is done with his review. PW is done with their review. -MS Public Works Review 09/24/2003 09/24/2003 APP MS 9/9/03 - Reviewed permit and ealeulated SDC eharges. Passed permit on to Ken Vogeney for legal review. After he reviews permit, it will be sent to planning. -MS Received plan back from Ken Vogeny. Okay to issue Same as 6772 Jacob Lane Structural Review 08/29/2003 09/2312003 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. ~eollirerUnsne('tions I I Sidewalk - Curbside: After forms are erected but prior to placement of concrete. 2 Curbcut - Standard: After forms are erected but prior to placement of concrete. 3 Vfer Electrical Ground: Install ground rod at footing and call for inspection in conjunction witb footing and/or foundation inspection. 4 Footing: After trencbes 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 Sbear Wall Nailing: Before covering sheatbing witb finisb materials. 9 Framing Inspection: Prior to cover and after all rougb in inspections bave been approved_ 10 Wall Insulation: Prior to cover. 11 Ceiling Insulation: Prior to cover. 12 Drywall: Prior to taping. 13 Final Building: After all required inspeetions bave been requested and approved and tbe building is complete. 14 UnderOoor Plumbing: Prior to insulation or decking. 15 Rougb Plumbing: Prior to eover and including required testing. 16 Water Line: Prior to filling trencb and including required testing. 17 Sanitary Sewer Line: Prior to filling trencb and including required testing. 18 Storm Sewer Line: Prior to filling treneh. Pa!!e 3 of 4 . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2003-00839 ISSUED: 10/07/2003 APPLIED: 08/28/2003 EXPIRES: 04/07/2004 VALUE: $ 175,410.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line 19 Final Plumhing: When all plumbing work is complete. 20 Undernoor Mechanical. Prior to insulation or decking and including required testing. 21 Undernoor Gas: After line is installed and required testing and capped if not attached to an appliance. 22 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. 23 Rough Mechanical: Prior to Cover 24 Final.Gas: When all gas work is complete. 25 Final Mechanical: When all mechanical work is complete. 26 Temporary Electric: Approval required prior to Utility Company energizing pole. 27 Rough Electric: Prior to Cover 28 Electric Service: Approval required prior to utility company energizing service. 29 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 ofany 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, thafnih~ermit card is located at the front of the property, and the approved set of plans will remain on the site at all t~s:;-/_ /~ /~C?-7 -~ ---=-- /' / Owner or Contractors Signature Date Paee 4 of 4 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 COM2003-00839 Payments: Type of Payment Check ~~,;J:"--:,"'.I, T'-'-" - "(, ! . ,.,. ,.' .,'" "",,~,.,~~,' -.,:,' . Receipt #: 1200200000000002283 Description Addressing Assignment Willamalane Single Family Residence Wiring 1000 Sq Ft Residence Wiring Ea Addtl 500 Temp Power 200 amps or less Sidewalk Permit Curbcut Permit PW Mult Disc - 2nd Permit Storm Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Transpo Reimbursemen1 SDC Transpo Improvement SDC MWMC Reimbursement SDC MWMC Improvement SDC MWMC Administration SDC Sanitary/S10rm Admin SDC Transpo Admin Annexed 2000 Building Permit 3 Baths One & Two Family Furnace - up to 100,000 btu Vent Fan Exhaust Hoods Appliance Vent Dryer Vent Gas OutleIs 1-4 -Mechanical Issuance Fee- + 7% Stale Surcharge + 10% Administrative Fee PaId By DENNIS MINIUM Received By djb l.:heck f\j umber Batch Number Authorization Number City of Springfield Offii:ial Receipt Development Services Department Public Works Department Date: 10/0712003 1:30:I3PM. Amount Paid 8.00 1,000.00 106.00 57.00 50.00 75.00 75.00 (30.00) 535.99 566.00 430.25 164.89 727.42 332.86 34.83 10.00 88.50 51.54 (1.41) 812.65 306.00 12.00 18.00 9.00 6.00 6.00 4.00 10.00 97.07 138.67 $5,701.26 . . Item Total: How Received In Person Payment Total: Amount Paid $5,701.26 $5,701.26 ",' . ~"""""~"""- '. .:01.,' . 1 ." ~'r.' .""1..<.....' .~.. ..Le..__.>....., '.. Hi'," (54i) 721),3753 FAX(541j726-3676 Estimated Base Flood Elevation & Disclaimer For property located at f,b'tD -:skolJ L/II . Springfield OR The calculated Base Flood Elevation (BFE) for lot# b5, Levi Landing - Second Addition is5/0. b 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 intelpretation of scientific and engineering evaluations known to the city at this time. Largerfloods 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 ji-ee " from flooding or flood damages or that conformance with the requirements of.the City will protect the property from flooding 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, _r-'""v;r j;/-::?,/~;C/;I/'- Signatu S L ~ ---:- Date /.e? ? -03 SThis copy to be signed by Owner's authorized agent and retained in City address file) CITY OF !INGFIELD SYSTEMS DEVELOPMErA.ORKSHEET JOURNAL OR JOB NUMBER: COM2003-00839 NAME OR COMPANY: Dennis Minium LOCATION: 6680 Jacob Lane TAX LOT NUMBER: 17023411 Tax Lot 09800 DEVELOPMENT TYPE: SINGLE F AMIL Y RESIDENCE NEW DWELLING UNITS I BUILDING SIZE (SF: 0 LOT SIZE (SF): I. STORM DRAINAGE, I I~ 10 10 l~ ItLl .f- r/) a ~ 10800 DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. x I COST PER S.F. CHARGE 1 I 1848.25 I $0.290 I = I. $535.99 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S.F. I x I COST PER S.F. I x I DISCOUNT RATE I I DISCOUNT 0.00 I I $0.290 I 50% = I $0.00 ITEM I TOTAL - STORM DRAINAGE SDC $535.99 $535.99 11070 2, SANITARY SEWER - CITY A. REIMBURSEMENT COST: . I NUMBER OF DFU's I x I COST PER DFU I 25 I I $22.64 $566.00 I 1091 B. IMPROVEMENT COST: I NUMBER OF DFU's I x COST PER DFU I 25 $17.21 $430.25 I 1092 ITEM 2 TOTAL - CITY SANITARY SEWER SDC = , $996.25 I " TRANSPORTATION I A. REIMBURSEMENT COST: I ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEWTRIPFACTORI I 9.57 I I I I $17.23 I 1.00 $164.89 11093 B. IMPROVEMENT COST: I I ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEWTRIPFACTORI I 9.57 I 1 I I $76.01 I 1.00 $727.42 11094 ITEM 3 TOTAL - TRANSPORTATION SDC = , $892.31 I 4 SANITARY SEWER - MWMC A. REIMBURSEMENT COST: INUMBER OF FEU's I x ICOST PER FEU I I I $332.86 = $332.86 11054 B. IMPROVEMENT COST: INUMBER OF FEU's I x ICOST PER FEU I 1 I $34.83 = $34.83 1055 MWMC CREDIT IF APPLICABLE (SEE REVERSE) ($1.41) 1054 MWMC ADMINISTRATIVE FEE $10.00 I 1056 ITEM 4 TOTAL - MWMC SANITARY SEWER SD< = I $376.28 I ~UBTOTAL (ADD ITE:"S I, 2, 3, & 4) = I $2,800.83 5, ADMINISTRATIVE FEE: I SUBTOTAL I x I ADM. FEE RATE I~ CHARGE I $2.800.83 I 5% I $140.04 TOTAL SANITARY ADMINISTRATION FEE: 88.50 1079 TOTAL TRANSPORTATION ADMINISTRATION FEE: $51.54 J 1078 Matt Stouder 9/9/2003 TOTAL SDC CHARGES = I $2,940.87 I PREPARED BY DATE I. . . DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE I """"'~, NUMBER OF NEW FIXTURES x UNIT EQUIVALENT - DRAINAGE FIXTURE UNITS i (NOTE, FOR REMODELS. CA1.ClILA TE ONL V THE NET ADDmONAL FIXTURES) NO. OF FIXTURES DRAINAGE UNIT FIXTURE NEW_ OLD EOUIV ALENT UNITS BATIlTUB 2 0 3 = 6 I DRINKING FOUNTAIN 0 0 1 = 0 I FLOOR DRAIN 0 0 3 = 0 I INTERCEPTORS FOR GREASE I OIL I SOLIDS I ETe. 0 0 3 = 0 IINTERCEPTORS FOR SAND I AUTO WASH I ETC. 0 0 6 = 0 I LAUNDRY TUB 0 0 2 = 0 ICLOTIlESW ASHER I MOP SINK 1 0 3 = 3 ICLOTHESW ASHER - 3 OR MORE (EA) 0 0 6 = 0 IMOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 IRECEPTOR FOR REFRlG I WATER STATION I ETC. 0 0 1 = 0 IRECEPTOR FOR COM. SINK I DISHWASHER I ETC. 0 0 3 = 0 I SHOWER. SINGLE STALL 0 0 2 = 0 I SHOWER, GANG (NUMBER OF HEADS) 0 0 2 = 0 I SINK: COMMERCiALiRESlDENTIAL KlTCHEN 1 0 3 = 3 ISINK: COMMERCIAL BAR 0 0 2 = 0 ISINK: WASH BASINIDOUBLELAVATORY 0 0 2 = 0 ISINK: SINGLE LAVATORYIRESlDENTIAL BAR 4 0 1 = 4 IURlNAL, STALL I WALL 0 0 5 = 0 ITOILET, PUBLIC INSTALLATION 0 0 6 = 0 ITOILET. PRIVATE INSTALLATION 3 0 3 = 9 MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 2S .EDU (Equivalent Dwelling Unit) is a discharge equivalent to a sin~e family dwellina unit (20 DFU's) set at 167 gallons oer day MWMC <;:REDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR CREDIT RATE/$I,OOO I --, ANNEXED ASSESSED VALUE IS LAND ELGlBLE FOR ANNEXATION CREDIT? BEFORE 1979 $4,92 I (Enter I for Yes, 2 for No) 1979 $4.92 I IS IMPROVEMENT ELGIBLE FOR ANNEX. CREDIT? 0 1980 $4.83 I (Enter I for Yes, 2 for No) I 1981 $4.77 il BASE YEAR .2000 1982 $4.64,.- I 1983 $4.47 CREDIT FOR LAND (IF APPLICABLE) 1984 $4,30 VALUE I \ODD CREDIT RATE' 1985 $4.09 $35.37 x $0.04 = , $1.41 I 1986 $3.78 I 1987 53.41 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) 1988 $2.98 VALUE 1\000 CREDIT RATE 1989 52.52 $0.00 x $0.04 0 1990 $2.06 I 1991 $1.64 1992 $1.45 TOTAL MWMC CREDIT = $1.41 1993 $1.31 1994 $J.J3 1995 $0.97 1996 $0.82 1997 $0.63 1998 $0.41 1999 $0.22 L 2000 $0.04 CITY OF &_JINGFIELD, OREGON () ~ City Job Number Date 1. I LOCATION OF INSTAlfATION , ~ola~\~ LEGAL DESCl~~'lON r.-.r\ l"1Q2:?An ' f1J,"f.U-J JOB DESCRIPTION ~ \. L\_ Permi are fll n- ransfer e and expire if work L not started wi 180 days of issuance or if work is Suspendedfor 180 days. I 3. 'j l()(o {V 1fl2!J 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 \ ~ $106.00 $ 19.00 $5'0.00 2. I CONTRACtORINSTALrA1Jo.N ONLY I Electrical Contrac10r STevE. i-Jt:Ivc.IL 5 4b ft, .>f- B. I~er"~ces o,r Feed~rs i: Irist~l~atio~l, M~~~~tiOlls. or -~~I?cation: .,". $ 63.00 $ 75.00 $125.00 . $163.00 $375.00 $ 50.00 200 Amps or less 201 Amps to 400 Amps /::)'V:o't- 401 Amps to 600 ~:~ ~~'\ 601 Amps to 11J..~~~ \~ ~~, - '01""5 Over 1000 ~~~ <( . Reco~~~ <\.~~ . _~~~ Q.. '\i, ~'" ~ ;\~;~~~~tflefvice~or'Feeders ~-<~~>(\~~~~~,'A1teration or ReIoeation ~ ~~~~psorless' l $50.00 ffipd ,,~~ ~ Amps to 400 Amps ~....o $ 69.00 ~ 40 I Amps to 600 Amps '" ,,\0. \~~.... I- $ I 00.00 ~0 v "...- Over 600 Amps or l}l{l!l''\!:\'I~s~''Bflibove. D.I BJ;anChCir~~'J.~::-~~;.~~t'\...'b' I . 0' '\$ ,~I/i ~ ,v_~"" New A1t~@iJOJ<Pt ~le~QI~~l.U'1 'i-l-O~ onh~R,<<>~,0 -<.,,~o ~O-v~ 0'" 0 ....~0 ;//,1> $ 43.00 ~l$l'e't1 Addl.!.i..QJlaI ~e~'\'l1ll0 ~O ^~'S~"<9";f'e~l'e?riiitn....0' .~~ _~~. $ 3.00 ~ . ~'. ~ _C\'\ _'0,1)' ~- \j" n''l-'' ~o ~fl ..,!,:'-' <I~' "C$: 0l1J.. . . I ,0., . leJl~/l1 .erdaon-elIer',io't illchlded) -Each Installation o 'J.(\.~" ,"".~.~ -. ' ~ ~ ~o '\(''' '\('0' '\' .' \~ f!!iIP~~l\~o!1t.\\c;, $ 50.00 . igw'€l~~ ~~ting $ 50.00 Limfl'e-a Energy/Residential $ 25.00 Limited Energy/Commercial $ 45.00 ~~8 Address City SPrl';)-fidJ. Phone ' 3.5 -r-1 ,.f - 04 141-bJ e . 'j '. Supervisor License Number I{) - Expiration Date Constr. Contr. Number L/ - 30 ~ 0 S Expiration Date "1 Signature of Supervising Electrician Z;e -Rat& Owners Name \:W (\ t\1.1'. ro.~ Address J3!l4~ \1\.u.A~ PL City, ~ Phone ~4.Q5 OVVNERINSTALLATION , 'The installation is being made on property I own which is not intended for sale, lease or rent. Minimum Eleetric Permit Inspeetion Fee is $45.00 + Snrcharges :1, 'l.'(fl!J rt~k '1.4t1:!fi 4. r 8.uBTOTJ,u. OF~OVF\ '\ Owners Signature: 7% State Surcharge 10% Administra1ive Fee Inspection Request: 726-3769 TOTAL Shared Drive(T:}fBuilding FormslElectrical Permit Application l-Q3.doc