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Home My WebLink AboutPermit Building 2003-1-13 Issued 225 Fifth Street, Springfield, OR 54]-726-3753 Phone 54],726-3676 Fax 54],726,3769 Inspection Line . ~ . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2002-01360 ISSUED: 01113/2003 APPLIED: 12/10/2002 EXPIRES: 07/13/2003 VALUE: $168,054.00 SITE ADDRESS: 46]9 Ivy St ASSESSOR'S PARCEL NO,: 1802051305200 Springfield TYPE OF Single Family Residence TYPE OF USE: New Residential PROJECT DESCRIPTION: SFR same as 4670 Ivy COM2002-0]359 Owner: MARGOLIS FAMILY LTD PARTNERSIDP Address: PO BOX 5442 EUGENE OR 97405 Contractor Type General Electrical Mechanical Owner Plumbing I CONTRACTOR INFORMATION I Contractor LARRY KENT COOPER DEANS ELECTRIC DEAN M SCHULTZ MARGOLIS FAMILY LTD PARTNERSHIP DENNIS SCOTT EGGERS # of Buildings: Primary Occupancy Group: Secondary Occupancy Primary Construction Type Secondary Construction # of Bedrooms: SETBACKS Front yard Setback: Side] Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Storm Sewer Available: Special Instruction: Notes: REQUIRED PARKING . Total: 2 2 Handicapped: Y CoDllllAU: es ~\)1"~ . 21.00 ~ \~ ,\\t. ~ ~'V"\ 'j,.,?\~'t;. ~\"\ ~ -I) ~ (..0\\1\ .d\~ IPUBLIC IMPRW'i"'::N:r~\ ~;~'t.~ '~;~'V'V~t." ~\:> ' l ~it'V ~~~ ~ e' Fullv Improved "\ ~"\\\'V\I\ ~rv't.'V ~'~Q,.\~ Typ . Yes ~ 'V~~'t: 'V~iJawitspouts/Drains c; ~\'( ,'Or;) 1'-" . 20.00 13.00 9.00 40.00 30.00 License ]09780 99579 133733 Expiration Date 11/06/2003 06/20/2004 02123/2003 Phone 54]-302-5852 54]-935-5303 54]-767-0626 ]42776 05/05/2004 54]-459-0110 ] R-3 U-I VN VN 4 I BUILDING INFORMATION I # of Stories: eS '10~ :~~ Lot Size: Height of . ~eo.~\~ 0(\ '<Z5~l!J~X' Sq Ft 1st Floor: Type OfH~'{il-~'<<~@\~~lirlS)o,\"sq Ft 2nd Floor: W~\!t~ eO'O'I~ ~~\eS Jtli~s'CSqFtBasement: ~~~gjO~~i~Ose ~"O ,~tiC~ ~eSq Ft Garage/Carport ~ ~~~~~ifh' O\~~O~'eSO' ~'Il0 ~\~q Ft Other: . ,o\\~'/'l~o(\ <'\'1_00\ .~CO~~ .\~e~:o\\~\c-a: Impervious Surface Area: .l....~ ,^n'v",\~\ ._.e. 'I'" "bB~Bi;di1ME~TJNF(H~Wt.lON~" . . ()~\J' .~,-,.- X\eu'. ~()U-V' o C'1>.\\\ ,'O~~ ~ \S .... ~'\WIaY_Rt~e ~ Street''frees Paved Drive Rqd: 490 7,711 ],]58 968 % of Lot Coverage: Curbside 5' Curb and Gutter I of 4 -.~?", ~':-".'!",! ".,C'",_,""; i) t," .." ,- "" , nl.-> " . .. d..".. .."t. , . . CITY OF SPRINGFIELD Building/Combination Permit Status: Issued 225 Fifth Street, Springfield, OR 54]-726-3753 Phone 54]-726-3676 Fax 54]-726-3769 Inspection Line PERMIT NO: C0M2002-01360 ISSUED: 01/13/2003 APPLIED: 12/10/2002 EXPIRES: 07/13/2003 VALUE: $ 168,054.00 I Valuation Descrintion I Description Dwellines Garsee Type of Construction V Wood Frame Garaee $ Per Sq Ft $74.60 $]9,60 Square Foomee 2,]24.00 490.00 Value $]58,450.40 $9,604.00 $] 68,054.40 Date Calculated ]2/]0/2002 ]2/]0/2002 Total Value of Project I Fees Paid I Fee Description Amount Paid Date Receipt Number Plan Review Same As $] 00,00 12/]0/02 21200200000000000369 -Mechanical Issuance Fee-- $10.00 1/]3/03 1200200000000000539 + ] 0% Administrative Fee $110.3] 1/13/03 ]200200000000000539 + 7% State Surcharge $96.52 1/13/03 1200200000000000539 3 Baths One & Two Family $306.00 1/13/03 1200200000000000539 Addressing Assignment $8,00 1/13/03 1200200000000000539 Annexed 2000 $-0.96 ]/13/03 ]200200000000000539 Building Permit $789,90 1/]3/03 1200200000000000539 Curbcut Permit $75.00 1/13/03 ]200200000000000539 Dryer Vent $6.00 1/13/03 ]200200000000000539 Exhaust Hoods $9,00 1/]3/03 1200200000000000539 Furnace - up to 100,000 btu $]2.00 1/13/03 1200200000000000539 Plan Review - Planning $55.00 1/13/03 1200200000000000539 PW Mult Disc - 2nd Permit $-30.00 1/13/03 1200200000000000539 Residence Wiring 1000 Sq Ft $] 06,00 1/13/03 ]200200000000000539 Residence Wiring Ea AddU 500 $76.00 1/13/03 1200200000000000539 Sanitary Sewer - Improvement $470.12 1/13/03 ]200200000000000539 Sanitary Sewer - Reimbursement $6] 8.52 1/13/03 1200200000000000539 SDC MWMC Administration $]0.00 1/13/03 1200200000000000539 SDC MWMC Improvement $34.83 1/13/03 1200200000000000539 SDC MWMC Reimbursement $332.86 1/13/03 1200200000000000539 SDC Sanitary/Storm Admin $]02.4] 1/13/03 1200200000000000539 SDC Transpo Admin $49.69 1/13/03 1200200000000000539 SDC Transpo Improvement $709.8] 1/13/03 1200200000000000539 SDC Transpo Reimbursement $160.87 1/13/03 1200200000000000539 Sidewalk Permit $75.00 ]/13/03 ]200200000000000539 Storm Drainage Impervious Area $705.85 1/13/03 ]200200000000000539 Temp Power 200 amps or less $50.00 1/13/03 1200200000000000539 Vent Fan $24.00 1/13/03 ]200200000000000539 Willamalane Single Family $1,000.00 1/13/03 ]200200000000000539 Total Amount $6,072.73 Plan Reviews I Initial Review 12/11/2002 12/12/2002 APP LLH 2 of 4 .~~. 'J~~....,.,....g.: ~:j \ .~'...." . :" ":, i~" ". '. .f . . CITY OF SPRlrlllT1'1J',LD Building/Combination Permit Status: Issued 225 Fifth Street, Springfield, OR 54]-726-3753 Phone 54]-726,3676 Fax 54]-726-3769 Inspection Line PERMIT NO: COM2002-01360 ISSUED: 01113/2003 APPLIED: 12/10/2002 EXPIRES: 07/13/2003 VALUE: $ 168,054.00 Plannin!! Review Public Works Review Structural Review 12/12/2002 12/12/2002 12112/2002 12/]912002 12/2412002 01/1312003 APP APP APP AID DPE 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. I Reouired Insnections I 1 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 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. ]] 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 Mechanical: Prior to Cover 24 Final Mechanical: When all mechanical work is complete. 25 Temporary Electric: Approval required prior to Utility Company energizing pole. 26 Ufor Electrical Ground: Install ground rod at footing and call for inspection in conjuction with footing and/or foundation inspection. 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. 3 of 4 Status: Issued 225 Fifth Street, Springfield, OR 54]-726-3753 Phone 54]-726-3676 Fax 54]-726-3769 Inspection Line . . CITY o~ ~rKINGFIELD Building/Combination Permit PERMIT NO: COM2002-01360 ISSUED: 01/13/2003 APPLIED: 12/10/2002 EXPIRES: 07/13/2003 VALUE: $ 168,054.00 By signatnre, I state and agree, that I have carefully examined the completed application and do hereby certity 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 ofthe 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 certity 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 t the front of the property, and the approved set of plans will remain on the site at a~onstruct'on. ~ \ ~ , 2..00 '?:> Owner or Contractors Signature Date 4 of 4 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Line Items: Job/Journal Number COM2002-01360 COM2002-01360 COM2002-0 1360 COM2002-0 1360 COM2002-0 1360 COM2002,O 1360 COM2002-0 1360 COM2002-01360 COM2002-01360 COM2002-0] 360 COM2002,O 1360 COM2002-0 1360 COM2002-0 1360 COM2002-0 1360 COM2002-01360 1/13/2003 3:18:32PM City of Springfield Development Services Department Public Works Department Official Receipt Receipt #: 1200200000000000539 Date: 01113/2003 . Amouul Paid 8,00 1,000.00 106.00 76,00 50.00 55.00 75,00 75.00 . (30.00) 705,85 618.52 470.12 160,87 709,81 332.86 Description Addressing Assigrunent Willamalane Single Family Residence Wiring 1000 Sq Ft Residence Wiring Ea Addtl 500 Temp Power 200 amps or less Plan Review - Planning Curbcut Permit Sidewalk 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 Page I 00 cReceiptrpt I J 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone C0M2002-01360 COM2002-0] 360 COM2002-01360 COM2002-01360 COM2002-0 1360 COM2002-01360 COM2002-01360 COM2002-0 1360 COM2002-01360 COM2002-01360 COM2002,01360 COM2002,01360 COM2002-01360 COM2002-01360 Receipt #: 1200200000000000539 Date: 01113/2003 SDC MWMC Improvement Annexed 2000 SDC MWMC Administration SDC Sanitary/Storm Admin SDC Transpo Admin Building Permit 3 Baths One & Two Family Furnace - up to ] 00,000 btu Vent Fan Exhaust Hoods Dryer Vent -Mechanical Issuance Fee- + 7% State Surcharge + 10% Administrative Fee Page 2 of3 ] / 13/2003 3:18:32PM City of Springfield Development Services Department Public Works Department Official Receipt 34.83 . (0.96) 10.00 ]02.4] 49,69 789.90 306.00 12.00 24,00 9.00 6.00 10.00 96,52 . 110.3] Line Item Total: $5,972. 73 cReceiptrpt ~~.._.."'i 1IIiit:~" I " .,. " I < ....n........ -_ -'w ,'..'--.-"...." ~ 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Payments: Type of Payment Check Paid By MARGOLIS FAMILY LTD Receipt #: 1200200000000000539 Date: 01113/2003 Received By Check Number C..finn N. DJB Page 3 of3 1/13/2003 3: 18:32P!<f City of Springfieltl . Development Services Department Public Works Department Official Receipt . How Received Amount Paid In Person 5,972.73 $5,972.73 Pavment Total: . cReceipt.rpt ~ ~i CITY OF SPRINGFUASYSTEMS DEVELOPM~T CH.E WORKSHEET JOURNAL OR JOB NUMBER: CO~02-01360 NAME OR COMPANY: Mar~olis Family LOCATION: 4619 Ivy SI I TAX LOT NUMBER: 18-02-05-13-04900 DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE NEW DWELLING UNITS: ] BUILDING SIZE: 2614 SF LOT SIZE: 7834 1. STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S,F, I 'I COST PER S.F, I 2503.00 $0,282 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS II IMPERVIOUS S,F, I xl COST PER S.F, J xl DISCOUNT RATE I 0,00 $0,282 50% 1 I ]TEM ] TOTAL - STORM DRAINAGE SDC 2, SANITARY SEWER - CITY A, REIMBURSEMENT COST: I NUMBER OF DFU's I 'I COST PER DFU 28 . $22.D9 B. IMPROVEMENT COST: I NUMBER OF DFU's I 'I COST PER DFU 28 $16.79 lITEM 2 TOTAL - CITY SANITARY SEWER SDC 3, TRANSPORTAT]ON A, REIMBURSEMENT COST: I ADTTRlP RATE I xl NUMBER OF UNITS I xl COST PER TRIP I xl NEW TRIP FACTOR I I 9.57 I I $16.81 I 1.00 ~I B, IMPROVEMENT COST: 1 ADT TRIP RATE I" I NUMBER OF UNITS 1.1 COST PER TRlP 1 _ 9.57 ~ I L $74.17 ITEM 3 TOTAL - TRANSPORT A nON SDC 4. SANITARY SEWER - MWMC A, REIMBURSEMENT COST: 1 NUMBER OF FEU's I 'I COST PER FEU 1 I $332,86 B, IMPROVEMENT COST: 1 NUMBER OF FEU's I 'I COST PER FEU 1 I $34.83 1 MWMC CREDIT IF APPLICABLE (SEE REVERSE) SUBTOTAL OF MWMC REIMBURSEMENT, IMPROVEMENT & CREDIT MWMC ADMINISTRATIVE FEE lITEM 4 TOTAL - MWMC SANITARY SEWER SDC I SUBTOTAL (ADD ITEMS 1,2,3, & 4) 15' ADMINISTRATIVE FEE: 1 SUBTOTAL I "I ADM, FEE RATE I $3.041.90 5% SF --I C/J W o o u ~ W E-< C/J ...... o ~ I xl NEW TRIP FACTOR I 1.00 =1 - - =1 ~I $705,85 II 111070 1091 I 1092 I 1093 11094 I =1 $34.83 I =1 1$0,96) I =1 $366.73 I 1055 =1 $10,00 I 1056 =1$376.73 II ~L $3.041.90 LJ TOTAL SANITARY ADMINISTRATION FEE: I TOTAL TRANSPORTATION ADMINISTRATION FEE: I =1 =L $705.85 $0,00 =1 $6]8,52 1079 1078 Stw<- 1~ SDC COORDINATOR DATE TOTAL SDC CHARGES =1 $3,194.00 I 12/24/2 002 ~I $470,12 =1 $1,088.64 $160.87 $709,81 $870.68 =1 $332,86 =1 $152.10 102.41 $49,69 r )' . . . DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVALENT = DRAINAGE FIXTURE UNITS II (NOTE: FOR REMODELS, CALCULATE ONLY THE NET ADDITIONAL FIXTURES) NO, OF F]XTURES DRAINAGE ( #NEW # OLD ) UNIT F]XTURE F]XTURE TYPE x EQUlV ALENT ~ UNITS BATHTUB ( 2 0 ) x 3 6 DRINKING FOUNTAIN ( 0 0 ) x 1 0 FLOOR DRAIN ( 0 0 ) x 3 0 INTERCEPTORS FOR GREASE / OIL / SOLIDS / ETC, ( 0 0 ) x 3 0 INTERCEPTORS FOR SAND / AUTO WASH / ETC, ( 0 0 ) x 6 0 LAUNDRY TUB ( 1 0 ) x 2 2 CLOTHESW ASHER / MOP SINK ( 1 0 ) x 3 3 CLOTHESW ASHER, 3 OR MORE (EA) ( 0 0 ) x 6 0 MOBILE HOME PARK TRAP (1 PER TRAILER) ( 0 0 ) x 12 0 RECEPTOR FOR REFRlG / WATER STATION / ETC. ( 0 0 ) x 1 0 RECEPTOR FOR COM, SINK / DISHWASHER / ETC. ( 0 0 ) x 3 0 SHOWER, SINGLE STALL ( 1 0 ) x 2 2 SHOWER, GANG (NUMBER OF HEADS) ( 0 0 ) x 2 0 SINK: COMMERCIAL/RESIDENTIAL KITCHEN ( 1 0 ) x 3 3 SINK: COMMERCIAL BAR ( 0 0 ) x 2 0 SINK: DOMEST]C BAR ( 0 0 ) x 1 0 WASH BASIN ( 0 0 ) x 2 0 LAVATORY ( 3 0 ) x 1 3 YRINAL, STALL / WALL ( 0 0 ) x 5 0 TOILET, PUBLIC INSTALLATION ( 0 0 ) x 6 0 TOILET, PRIVATE INSTALLATION ( 3 0 ) x 3 9 MISCELLANEOUS DFU TYPE NUMBER OF EDU's' ( 0 0 ) x 20 0 TOTAL DRA]NAGE FIXTURE UNITS =1 28 .EDU (Equivalent Dwelling Unit) is a discharge equivalent to a single family dwelling unit (20 DFU's) set at 167 gallons per day MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE IF IMPROVEMENTS OCCURRED AFTER ANNEXATION DATE, CALCULATE CREDIT SEP ARA TEL Y II YEAR CREDIT RATE PER $1,000 II YEAR CREDIT RATE PER $1,000 ANNEXED ASSESSED VALUE ANNEXED ASSESSED VALUE 1979 OR BEFORE $4,92 1990 $2,06 1980 $4,83 1991 $1.64 1981 $4,77 1992 $1.45 1982 $4,64 1993 $1.31 1983 $4.47 1994 $1.13 1984 $4,30 1995 $0,97 1985 $4,09 1996 $0,82 1986 $3,78 1997 $0,63 1987 $3.41 1998 $0,41 1988 $2,98 1999 $0,22 1989 $2,52 2000 $0,04 CREDIT FOR LAND (IF APPLICABLE) CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALUE / 1000 CREDIT RATE 23.882 X $0,04 =1 0.000 X $0,04 =1 TOTAL MWMC CREDIT =L $0.96 $0,00 $0,96 ,,'i)- '\"'~ .~00 C~\V :0<" ~<ie i}~7~ ?:;~225,FIFTH,.STI'EET r .;;; ,,~~:" ,\7,-A; '" EL~C~HER:'vllT AP~L,!CJ\TIO)'l, :5.:'- i';h~ 1.1':.iSPRlNGFIELD OREGON974Ji1:1~~ . <; '" .-,';,': .{:-'. ,,"'~~"~f.;" ' "":'~"r-:f~i~"'''' ~~J~: "'1,I~sP~c:r:[6'{P.r:Qvss1:~1' ^~,'9'~" ' ';,: ~Cit;-'joh N~';i)e;;W;,":., '~"}\\~~~l~,; \:';~.'" iOFFI.CE. ;;i726.'3.759)~~,.~~(\<)~. . ".~." ~ ~ ~Jf~J"~~~"''"~I.~tt~:'~~'1 i'~,.m ~.,. ~?{;ThI ~ ~)~~~)~<~ '. - ',. 3..,COMPLETEFEE'SCHEDUtitBEL0\V';' ;c~J;>:~~~~~~~ j!i~~~ J,il'.ij''''C~'Tg,:' ON~"F~iN'S '. 'uti :,.' " ~~~' J;~tit.~'t%W.""'~"9:i" ,,~';i~}:~':~if.. ~~,."'- 'l+ ,...j....., f,.or _c'" '~""",,-'-;1PF'':'~ ~1;'~~- ~"'" .l""to::.;.x".:.....,.~'1":.iAP4..~1 ~.~..:;\J ;n ~. .1. _' ~ '(J, . ~ Ne'l.'lRcsidcntial~Sinole 6r"':;.o;: J\:;....\~,,~~ . ~'1'''''''__ ~~- "~~-!i{ ~'L - - - :t'-J.'" ~- ~ ,~o Multi-Family per dwelling unit. "~':,. , ~EGAL ESCRIPTIO, \'~ Service Included: ,:.~,~ f'C.\Q .~...,.~, "'':{t'~i:'' . IJH0 D0 ~ 'll_J Items Cost Surn:1:t JO~. s~ ION. ~\&:t~ i~::~;,:~~OO -L"oooo~l~ Permits are lion-t ,nsferable an~XPire :1;~~Oo: portion f 4- $ 19,00 ,;Jtio~ iffwork is not;~tfartedk\:ithin lsoddal; rvElacdh MaDlU1fdl Home or """:,':"~~"~:~,~,:,',,,.;.:,','.;,,'..':,.,., ".. o Issuance ~2i~-.1 \vor. IS suspen ed lor 0 uIar \\'e lIng .,,::;:,;....: :,;'~,~,<>.~.l,i"..;.:."',;:~, 180 days: ~,~~,;,',:.~,l.';,;-i, Service or Feeder .~.)~~~. t,\t.t~:'~:;'j; $ 50.00 ~:- ~ ~".. .. ;~;~~"._~ l!.1?t"lJ .' ~}{ E2'leCCIOriNTc' al,RA.~:i:-"'"."o'~,',',_('n:.-CT'~':~:"':~~':.r"'.:<a'OctRo~~~"'.'.,:,."""",.,:,~',S".:T)ALp'JAL\^JATSION~O'INLe~YR\'L- B. .Services or Feeders .~~ '..~:!;~j:pi,. ,lS~\ ..".- .., .- Installation, Alterati~n's,6r '"'::~j;I;1'tt'';;':~':::- ~':)~~ Relocation: '-~:~~~~ i\;:~;... ~I~i"i; m~! (J-"" "'\.r~};',~~f;;" ,~f! Address ,~~~~ D~~ I).;~~C;- :]~1~'f$1j~8'.)~ , (~ ~t-\01- "",~~:j~\15;:~;;?,~~ Cll)' i~~lN&'.l''''~hone 9, _ :~.~:'i$125:00':io'!t",~ '~::: ~c.:n" '.~"l'-'~~~:6'."~~0'.0"'.'"'--:J:'F-tt' ~ :#.J~;,i.vi .' "'''''' ""..], 3: ,i,w~:<;~ SUP~f\,'iSO.'i/[~i,c_e~.'~,efN[;~er .~.....,.. .",~..."~. ' ~~'$3fi5YOO'Jer~ ~~~ . ',,,,... .;$~h~~:,;~ E~.irati~..~. D~at'lf.l~~.:'(~~~i.',.=:~ll1i.:";"'''' "."^--; ~~~~~!lJt~ >EXPira~i::::~~~"" '." ',y.., . ~" . ''''''~''S:~:'J ' ~."~11L:... .~ ~ :.1),=-~~~~~~~~. 'yners-Na c~. _;~ ',: ".;" ~~ , fii>l~_'~' ..,.,,~~~., IjJf!? I -;" . ~..t,.~ '0,; ':eil~~~ ,",-- . J~' : r};'~ {eqU\{~ ,~ ".. ;;'<1,dress,," ,!ff:l~":':"~".", " OneCl\~e90(1", Q'," $4~,9Q~'--'--'-=li: ~t"j~~~Fi',?f.,~;*~~~;~?~:,:~'i]i&~. f\ ~,,~ !\IIEN~4)!~~~Ji4~' I\M ti~~he. ~::~{~~~~l\WFtt.:~f~t . ~~:;iF}~S~ty,:.~ ,,,,,,,., .,-,~,Pho,~,t~ ~ IO\\?W ~t' 1l( W~rl\OI"WA:R~5'?.~0:1~,' ~%' \o:''';~' ';':;~{:;~!:' ;i;::;,'t;:}., :~;i~'!::':l~l?:i; NO\ihcatiiJF\i. ~.l'U\'Oth~hOA ~~tOOf":_.,.< !"",'''';'J''':~OWNER INSTALLATION 4<;".''';' . OAR 952.~~" . ce,plesoHhe 'e',.'1-' .' ,.' ':': ~f./;(\"(~:rhe 'instaliati6nis b~;hg. ;n~dt..9.;n..'.'~.f{..' ~\)~e~l\tdun'li8lMi1\~~!ttlli'o'tEi~l~on" <,~" , '.:'L:Iff(~W~~;~: i~E~;I~~~,~~::t inij[~i.~f.~~;;:i . n~~i:~~~lg~~~:~,'ca i;~:~~ ":, .::" _:;:.j'O'~'ncr~ S,~.,g,..,~ature.; . "". ;'<~<"'. Limited EnergylRe?".... $25.00 ,'.' : '..... "":'~::/:>:": Limited Energ)'/Comni $45,00.' -::,," ...\..,.-:L., *1' ~~~A~. ~:.t~.1'" "i}~"C ~"'>"".'; ,'"...~.. "~f"'" }~i~~ i~;~'. ~#7'.;"""'! ~~~~~{~ f~t'~~i' ;:~~ >k"'~ ': l' F -- . .~. : " ' i\lii1imum ~Icctric Permit Insjlcctioll Fcc i.s S-t5.0n + Surcharges } ,'.." j:;'./ ,'0 ....-. .....,.,...,'.. . }";;~:LS~j . .:::~;:',:\,',:f,'~'"i?: ,'. 'i.,'(,," .' :~jt". ""'. _~ TOTAL ,', ,,' 4. SUBTOTAL OF ABOVE 70/0 State Surcharge 8% AdministJ'Uti\'e Fee' 2..tJ{L~ - \t(').~ I~~O ~ i'- ...:".: ':"' "'. ,.. '1 ( .;. .. . .~ ,-, ,-" .,.".