HomeMy WebLinkAboutPermit Building 2006-6-6 . 225 Fiftb Street, Springfield, OR 541-726-3753 Pbone 541-726-3676 Fax 541-726-3769 Inspection Line * 't . CITY OF SPRINGFIELD - , Building/Combination Permit PERMIT NO: COM2006-00515 ISSUED: 06/0612006 APPLIED: 05/02/2006 EXPIRES: 12/06/2006 VALUE: $ 2,950.00 j', '-:-~:''T')hl: Orn,:on I~w reCiI 'Ires YOLl to Status Issued l,.\~'./r,". i '\.:_"" ._~'ll::';<)I:"'~;UIIUtlIllY SITE ADDRESS: 3527 KATHRYN AVE ASSESSOR'S PARCEL NO.: 1702304300900' '.f. - ,,'......".r. t I ...,.~en.r...'t.::areC""'{TOnn Springfield TYPE'OF WORK!'Mannfactured'Home on I'r' ll"" ,\ 'J.nfl", ,.., Oil' \ ' ('" If "1 I ]J\!i \.':.)~-UU1- . ,.1 ........_ ,-..J...\I PrIvate L.;ot v C03CTY'PErOFiUSE,.in rN'eW"S 01 the rules k1'sidential PROJECT DESCRIPTION: Manufactured bome on private lot, See (lOiVI2006'00514'for i"Dd'Cr~dii;elepl1one numoul fOI the 01 "Son Utility Notification Owner: LYDIA E SENTER REVOC TRUST Address: 3529 KATHRYN AVE SPRINGFIELD OR 97478 Vt:lllt:l I:;' l-OVU-vv.::..-.c.........,...,.,. Pbone Number: 541-726-5749 , CONTRACTOR INFORMATION I Contractor Type General Electrical Manuf Home Inst Plnmbing , Contractor HARRISON JACOBSON INC MAG ELECTRIC INC HARRISON JACOBSON INC HARRISON JACOBSON INC License 66447 149834 66447 66447 Expiration Date 05/07/2007 12113/2009 05/07/2007 05/07/2007 Phone 541-689-7762 541,461-0387 541,689-7762 54 I ,689-7762 VN BUILDING INFORMATION I 'I 01 ",LL E" _ "u ., ',cU UNO ,~F/HE IF T # of Stories: ",,':'/'ICIVL'tu O~ ER.i[JtISi~eU<M/~E WORK HeigbtofStructure "J U"y PrQ/S fSq;f..tJ&\\r,I~or:IS NOT Type of Heat: orced Air Electric/OO,Sq Ft 2nd'Floo6R Water Type: Electric Sq Ft Basement: Range Type: Electric Sq Ft Garage/Carport Energy Patb: Sq Ft Otber: Sprinkled Building: n/a Occupant Load: 1,188 # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Constrnction Type Secondary Construction Type: # of Bedrooms: I R-3 3 I DEVELOPMENT INFORMATION I REQUIRED PARKING Frontyard Setback: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: 60,00 11.00 5,00 15,00 0,00 Overlay Dist: # Street Trees Rqd: Paved Drive Rqd: % of Lot Coverage: 2 Total: Handicapped: Compact: 2 19.80 I PUBLIC IMPROVEMENTS I Street Improvements: Storm Sewer Available: Special Instruction: Partially Improved Yes Sidewalk Type: DownspoutslDrains: To Cnlvert - Provide Drainage Plan Notes: Storm drainage piped into existing ditcb 5/5/06 CAS Pa2e I 00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541,726-3676 Fax 541-726-37691nspection Line Description Tvpe of Construction Foundation Onlv Use Bid Amount Manuf Home Manufactured Home Fee Description Plan Review Resideutial + 10% Administrative Fee + 8% State Surcharge Manur Home State Issuance Manufactured Home Placement Manufactured Home Service Piau Review Minor, Planning Sanitary Sewer - Improvement Sanitary Sewer - Reimbursement SDC Sanitary/Storm Admin Storm Drainage Impervious Area Storm Sewer - 1st 50 Feet Storm Sewer Each Addtl100' Total Amount Paid Initial Review Plan nine Review 05/04/2006 05/04/2006 Public Works Review 05/04/2006 Structural Review 05/04/2006 . I Valuation Descriotion I $ Per Sq Ft or multiplier $1.00 $1.00 Square Footage or Bid Amount 2,950.00 50,000,00 . CITY OF ~rK11~ld<u'LD Building/Combination Permit PERMIT NO: COM2006-005I5 ISSUED: 06/06/2006 APPLIED: 05/02/2006 EXPIRES: 12/06/2006 VALUE: $ 2,950.00 Value Date Calculated Total Value of Project )(pp~, ~ Amount Paid Date Paid $2,950.00 $50,000.00 $52,950.00 05/02/2006 05/02/2006 $34.32 $26.90 $21.52 $30,00 $160,00 $50,00 $112.00 $190.70 $250.70 $31.18 $182.17 $45.00 $14.00 5/2/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 6/6/06 Receipt Number 1200600000000000589 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 1200600000000000798 Provide 32 sf of enclosed storage. If there are existing street trees, they maybe used for the street tree requirement. Storm to roadside ditch 5/5/2006 CAS RWC 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, $1,148.49 I Plan Reviews I 05/0412006 OS/22/2006 APP LLH APP TAJ Manuf Home Set Up: When installation of all piers or stands is complete. 05/05/2006 APP CAS OS/25/2006 OK ~lrrJlir~rI .nsnections I Paee 2 of3 . . LIlt OF ~rK11~'..d<1J'.,LD Building/Combination Permit PERMIT NO: COM2006-00515 ISSUED: 06/06/2006 APPLIED: 05/02/2006 EXPIRES: 12/06/2006 VALUE: $ 2,950.00 Issued 225 Fifth Street, Springfield, OR 54]-726-3753 Phone 54]-726-3676 Fax 54],726-3769 Inspection Line Final Mannf Home Set Up: After all reqnired inspections are requested and approved and porches, skirting, decks, venting, street address numbers, trees, driveway, etc. have been installed. Manuf Home Plumbing: After home has been connected to water and sewer. MH Service: Approval required prior to utility company energizing service. Storm Sewer Line: Prior to filling trench, By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all information bereon is true and correct, and I further certify tbat 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 berein, 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, tbat 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, ~ ~~ 6-6-o~ Owner or Contra~or; s~re - Date Paee 3 of3 rT:~~r,. , t' -<e,,' ..,~"~" .;>'h? c..nOI 225 FIFfH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 ~i~ltf~:ii;~,""'i~,~--J ELECTRICALPERMITAPPUCATION " 'Date ~'" '"I'iU.:a"L:'i!';i'~" ,I", City Job Number Q.l o. ~\5 v L \' I. 3. fCOMP.iill:i:tl;;~ETseHE.6'VLE;iiEooWl';""J,'It~w.~~~ l~'_--'"",""___-'_.J"'''_~i"~,,,,,..n&.;n,"~.~~~~~~~' ~},~(:{>:'\,": 'diT:\f'(DF.l:'!RLNGFIELD OREGON: "~J" -~.;: ':z.,'(..).;1r-:--"'",:-" . ~ .. T' .~'_~ .:-..8...'..... ~', .'. ., -. '. '. ' '-! ;' tJ:Otl) lOB DESCRIPT[ON per~r~nr~:d'exp~b not started wlt~~~V::O days of issuance or If work b Suspeuded for 180 days. ~eoN7fRAero~fir7i!;riiOMONE~' 2. ~~:,!i!.--=-~W9~~J:L-!;' ,'-.. ' ".~ . Electrical Contractor Address City ~...(;fIL Phone Supervisor License Number A./1,/(1 5 Expiration Date / () -I -D 7 . . Consll'. Conb'. Number I 19 ~,7;, ~' Expiration Date, /<1 /1.3 I d1 j '" Signature ofSupeivising Electrician ~4C-'/1--~ OwnersName Lw\\a. ttrkf- Address ~ ~QJ~ \c:' MH R.\-\.lU City ~('\C\[\~~,1(t Phone i1..~'~1'\4 OVVNERINSTALLATION The installation is being made on y.vy.../ [own which is not intended, for sale, lease or rent. Owners Signature: [uspectIou Request: 726-3769 A. ~f:Niw~iamttii[~siri~i~~1\iNffiSF.1i~ii;.1!.1'~~dw~iiili~~cr.ii,~~j ~~~..........."".~_~.,~.."..".,~...:..,-_ ,.._.l...R.,.1i:!......u..,g-,-L~~ Service Included t 000 sq. ft. or less SI06,OO Each additional 500 sq. ft. or portion thereof S 19.00 ^T-"'r--.TTrr-". r.- ,_, IEa~hMaoufact'([Home'ora"" requires YO'l to 0 , Modular DWelling SerViceo.rlS Oreoon U' \il,'1 S'50 00 ",.r\0 r'CF' d" (' ',~ y. 0V. in e~ n~~~ ::--~ntsr, Tllose rules are set lorth C'ull~~!'!r"~"""'-f!iI.l~'~""''*~''''''''''''''~1.''''''''''~r,1 t!I.i,~~~~rS,-'IoSpillali!l'!.~lte.ralj9!1~~t'RC,log~M:l , . -1-.-.... VI "IG I UIC'~ ~~'~~q~ster, (Note: the telephontS 63.00 nw IOU'" Jor InA Orf'Clf) Ut'/'t N " , 201 Af11P.s to 400 A~ n I r y' otlllcatlos 75.00 401 A~I~1fo\Y A~~O'332-2344), S125.OO 601 Amps to [000 Amps S163.00 Over 1000 AmpsIVolts S375.00 Reconnect Ooly S 50,00 - .. C r;:.:.W'<~"'=,' "S='''''~'''''''--F.,]:''','d."^,..,,l;qr,Jr.~,'~,'' '~ . ~,'emp~~~:MS!?!!~'~~.Hg~~r..s~~:i.it~~.~', ',;;e-;t! Instal[ation, Alteration or Relocation 200 ~~I'1."Jess S50.00 f 20l'AlI)P.S to 400 Amps'S 69.00 401~~'tot6001W~ALL EXPIRF IF nj~loo,ooK U I nUHILtD I i~IOr:Q TI-IJn n_ VVUH <>ver,6OjlrAmpsorr[OOO Volts see~B"iailO~'eT D: ~Bifafi'Cii@~~~~ilJ- :' "..,"'"..'."'€'N~l _._._~~U ..-_ L" .'u. ~~~,~'"""'- 'i...~t~ New A[teration or ExtensioD Per Panel Ooe Circuit Each Additional Circuit or with Service or Feeder Pennit .. S 43.00 S 3,00 ~ c:::: E; ~~b~~t~~iI~f;1Jilfi.rl~did"')ilJ"r"~,'."",;u..",an,,~ 1~.~.-"t!T"::>'.r..-~.'.c~'.;;I.-~....~~.. .Ir.... ~~u-:Ji . ,.. . ,~"-,, Pump or irrigation S50.00 i' Sign/Oudine Lighting S 50.00: ;{ Limited EoergylResideotial 's 25,00 "r:'" Limited Energy/Commercial S 45,00 Minimum Electric Permit Inspectiou Fee b $45.00 + Surcharges ~...,_.~;., ~!:i>~~%~_'~',;~,;,~;(~:r.'?~;~~!!i.,':1i~ 'C{) ,{) 4. 'SVBT01ID;'OEABOVEt~~~~~1J;"\\!,,,~(:'! UV , ~ ';'~'U'Jl:'o'.~....l;,,':'~~','Wi'lTi.P~f\oi~.'t'\o!:~i~W:~~;;~", 'Mt\i-~a~~ . 7% State SU~harge ,'-'~ ' A.. ex:> 10% Administrative Fee c:::.. ()(.) "-" oJ TOTAL ~. Shared Drive(T:)lBuilding Forms'Elcctrical Pennil Application I-OJ.doc CITY OF tllNGFIELD SYSTEMS DEVELOPME&ORKSHEET ", JOURNAL OR JOB NUMBER: NAME OR COMPANY: LOCATION: TAX LOT NUMBER: DEVELOPMENT TYPE: NEW DWELLING UNITS C0M2006-00515 Lydia Senter 3527 Kathrun 1702034300900 SINGLE FAMILY RESIDENCE o BUILDING SIZE (SF' 1188 LOT SIZE (~~): I. STORM DRAINAG\l DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S,F, x I COST PER S,F, CHARGE I 564,00 I $0.323 I = I $182,17 I RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S,F, I x ! COST PER S,F, I x I DISCOUNT RATE I I I 0,00 I $0.323 I I 50% = I ITEM I TOTAL.. STORM DRAINAGE SDC $182,17 I 2, SANITARY SEWER, DTY A. REIMBURSEMENT COST: I NUMBER OF DFU's I x I 10 I COST PER DFU $25,07 B. IMPROVEMENT COST: I NUMBER OF DFU's I x I 10 $19,07 ITEM 2 TOTAL, CITY SANITARY SEWER SDC =, $441.40 ,1 TRANSPORTATION A, REIMBURSEMENT COST: I ADT TRIP RATE I x I 9.57 I B. IMPROVEMENT COST: I ADT TRIP RATE I I 9,57 I I NUMBER OF UNITS I x I I 0 I I COST PER TRIP $19.09 x I NUMBER OF UNITS I x I I 0 I I = , COST PER TRIP $84,19 $0,00 4 SANITARY SEWER, MWMC ITEM 3 TOTAL .. TRANSPORTATION SDC A, REIMBURSEMENT COST: INUMBER OF FEU's I x I 0 I B, IMPROVEMENT COST: INUMBER OF FEU's I x I 0 I ICOST PER FEU I $82,03 ICOST PER FEU I $865.31 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL-MWMC SANITARY SEWERSDC =, SUBTOTAL (ADD ITEMS I, 2, 3, & 4) ~ , ~ AOMTNISTR.<\TlVE FEE: $0,00 5623.57 I SUBTOTAL x I ADM, FEE RATE I $623,57 I 5% TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMJN]STRATION FEE: I~ I CHARGE $31.18 Cheryl Slaymaker 5/5/2006 1079 ! 1078 PREPARED BY DISCOUNT $0,00 6000 ~ 1m lEi 10 u I~ m G ~ $182,17 $250,70 $190.70 11070 11091 I 11092 I x INEWTRlPFACTORI I 1.00 I x INEW TRIP FACTORI I 1.00 I $0,00 $0.00 11093 I 11094 I DATE TOTAL SDC CHARGES = $0,00 11054 I I I 1055 I 1054 $0,00 I 1056 ~ J = $0,00 $0,00 31.18 $0,00 $654,75 . . " DRAINAGE "lA> uRE UNIT (DFU) CALCULATION_TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVALENT - DRAINAGE FIXTURE UNITS (NOTE: FOR REMODELS. CALCULATE ONLY THE NET ADDmONAL FIXTURES) NO, OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUlV ALENT UNITS BATHTUB 2 1 3 3 DRINKING FOUNTAIN 0 0 1 = 0 FLOOR DRAIN 0 0 3 = 0 INTERCEPTORS FOR GREASE lOlL I SOLIDS I ETC. 0 0 3 = 0 INTERCEPTORS FOR SAND I AUTO WASH I ETC. 0 0 6 = 0 ILAUNDRYTUB 0 0 2 = 0 ICLOTHESW ASHER I MOP SINK 1 0 3 = 3 ICLOTHESWASHER, 3 OR MORE tEA) 0 0 6 = 0 , " IMOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 IRECEPTOR FOR REFRIG I WATER STATION I ETC. 0 0 1 = 0 IRECEPTOR FOR COM, SINK I DISHWASHER I ETC, 0 0 3 = 0 ISHOWER. SINGLE STALL 0 0 2 = 0 ISHOWER. GANG (NUMBER OF HEADSl. 0 0 2 = 0 ISINK: COMMERClAURESIDENTIAL KITCHEN 1 1 3 = 0 ISINK: COMMERCIAL BAR 0 0 2 = 0 ISINK: WASH BASINIDOUBLE LAVATORY 0 0 2 = 0 ISINK: SINGLE LA V ATORYIRESIDENTIAL BAR 2 1 1 = 1 IURINAL, STALL I WALL 0 0 5 = 0 ITOILET. PUBLIC INSTALLATION 0 0 6 = 0 ITOILET. PRIVATE INSTALLATION 2 1 3 = 3 MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 10 .EDU (Equivalent Dwe1lin~ Unit) is a disc~ eQuivalent to a sins::le family dwellinJ!: unit (20 DFU's) set at 167 ~Ions per day MWMC CREDIT CALCULA nON TABLE: BASED ON COUNTY ASSESSED VALUE I YEAR CREDIT RATFJ$I,OOO II ;r ANNEXED ASSESSED VALUE IS LAND ELGlBLE FOR ANNEXATION CREDIT? I BEFORE 1979 $5,29 (Enler I for Yes, 2 for No) I 1979 $5,29 IS IMPROVEMENT ELGIBLE FOR ANNEX, CREDIT? 2 I 1980 $5,19 (Enter I for Yes, 2 for No) I 1981 $5,12 BASE YEAR 1979 I 1982 $4,98 I 1983 $4,80 CREDIT FOR LAND (IF APPLICABLE) I 1984 $4,63 VALUE I 1000 CREDIT RATE I 1985 $4,40 $0,00 x $5,29 ~, $0,00 I 1986 $4,07 ~ 1987 $3,67 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) 1988 $3,22 VALUE I 1000 CREDIT RATE I 1989 $2,73 $0,00 x $5,29 0 I 1990 $2,25 I 1991 $1,80 I 1992 $1,59 TOTAL MWMC CREDIT = $0,00 I 1993 $1.45 I 1994 $1.25 I 1995 $1.09 I 1996 $0,92 I 1997 $0,72 I 1998 $0,48 I 1999 $0,28 I 2000 $0,09 2001 $0,05 , . 225 FIFTH STREET SPRINGFIELD, OR 97477 (541) 726'3753 FAX (541) 726,3689 www.ci.springfield.or.us MANUFACTURED HOME SET,UP AGREEMENT As required by the City of Springfield Development Code; I understand and agree that with the appIJlval of the attached pennits, one of the following manufactured homes will be placed at -:0., ~ L T- K.~ "'t-' , Springfield, Oregon, City Job Number ee......,~"'.... - L,- 1'::,- -----= ....... ' Type-lNlanufactured Home: 7- ----- ' \. A multi sectional (double Wide or Wider) umt With an enclosed floor area of not less than 1,000 square feet, that has a nominal roof pitch of 3 feet in height for each 12 feet in width, that has no bare metal siding or roofing, and dlat has been certified by the manufacturer to have an exterior thennal envelope meeting perfonnance standards which reduce heat loss to levels equivalent to the perfonnance standards required for single family dwellings at the time of construction, ~ A unit of t less than 12 feet in width enclosing a minimum floor area of 500 square feet; that has a 'nominal roo 'tch of 2 feet in height for each 12 feet in width, that has no bare metal siding or roofing, and that has bee . ertified by the manufacturer to have an exterior thermal envelope meeting performance standards which re e heat loss to levels equivalent to the perfonnance standards required for single family dw~llings at the ' e of constlUction. initials I further state, by my signature below, tj1at I have been provided with the following infonnation: Manufactured Home Blocking, Water Line Connection, Street Tree Standards, Sanitary Sewer Connection, Electrical Connection, and Minimum requirements for pennanent steps. I also understand that the manufactured home shall be placed on an excavated and backfilled foundation not to exceed 6 percent slope within 10 feet afthe perimeter enclosure, enclosed at the perimeter with stone, brick or other concrete or masonry materials approved by the Building Official and with no more than 24 inches of the enclosing material exposed above grade, ' , ~ j " .~/~ (~ ~ ,/' /---- b-~-t/~ Date I I I I <, < I 01 . . MANUFACTURED HOME LAND USE AGREEMENT As required by llie City of Springfield Development Code, I agree that wi~ the ~roval of ~.it:ched permits, one of the following manufactured homes will be pla~d ~.3 :::. "Z' / 1:: rl'_ Springfield, Oregon, City Job NumberCOwc ~-OO ~ I:::. , ' '~ 'T~anufactur~ome. A multi-seCtional (double wide or wider) unit with an enclosed floor area or;o; i;~s than_I,O?o';quare feel, that has a nominal roof pitch 00 feet in height for each 12 -- feet in width, that has no bare metal siding or roofing, and that has been certified by the manufacturer to have an exterior thermal envelope meeting performance standards which reduce heat loss to levels equivalent to the performance standards required of single family dwellings construcied under the State Specialty Codes. _ Type II Manufactured Home, A unit of not less than 12 feet in width with an enclosed floor area of not less than 500 square feet, that has a nominal roof pitch of2 feet in height for each 12 feet in width and that has no bare metal siding or roofmg. The manufactured home shall be placed on an excavated and back,filled foundation not to exceed 6 percent slope within 10 feet of the perimeter enclosure. The perimeter foundation wall surrounding the home shall be constructed of stone, brick or other masonry materials, and with no more than 24 inches of the enclosing material exposed above grade. I further agree to meet all land use and City Code requirements of the above mentioned parcel within 60 days of the date of issuance of the manufactured home set up permit. These requirements may include, but are not limited to the items listed below. Specific land use requirements regarding your parcel are noted on your approved set up plans andlor permit and your partition approval if applicable: . Street Trees . Paving Driveway . Minimum 32 square foot storage structure . Completion of partition approval . Removal of any existing structures as noted on your partition approval . Signing and recording of any required partition, easement, improvement agreements, etc. . Final lot grading . City Sidewalk and curbcut installation . Any outside agency approval as required i,e., Division of State Land approval. By my signature below, I agree to complete the above mentioned land use requirements. Owner Signature ;I ~~~;P'\ Contractor4I'g6arirry j , Date h~ 6-0? ~ Date 225 Fift~ Street' . Springfield, Oregon 97477 541~726-3759 Phone Job/Journal Number COM2006,00515 COM2006..00515 COM2006..00515 COM2006-00515 COM2006,00515 COM2006-00515 COM2006,00515 COM2006-00515 COM2006,00515 COM2006-00515 COM2006,00515 COM2006,00515 Payments: Type of Payment Check cReceintl . ~,"., ~ ~.-._.., ~ ~ of Springfield Official Receipt .elopment Services Department Public Works Department RECEIPT #: 1200600000000000798 Date: 06/06/2006 8:21:2IAM Description Manufactured Home Service Storm Drainage Impervious Area , Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Sanitary/Storm Admin Plan Review Minor - Planning Manufactured Home Placement Manuf Home State Issuance Storm Sewer, 1st 50 Feet Storm Sewer Each AddU 100' + 8% State Surcharge + 10% Administrative Fee Amount Due 50,00 182,17 250,70 190,70 31.18 112,00 160,00 30,00 45,00 14,00 21.52 26,90 $1,114.17 Paid By GOODEN,HARRISON Item Total: <':heck Number. Authorization Received By Batch Number Number How Received Amount Paid njm In Person Payment Total: $1,114,17 $1,114.17 9704 Page I of I 6/6/2006