HomeMy WebLinkAboutPermit Building 2004-10-7
Building/Combination Permit
PERMIT NO: COM2004-01136
ISSUED: 10/07/2004
APPLIED: 09/14/2004
EXPIRES: 04/07/2005
VALUE: $ 176,817.00
.
.
Status
Issued
~
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-37691nspection Line
SITE ADDRESS: 196 Kaylee Ct 198
ASSESSOR'S PARCEL NO.: 1703271103000
CITY OF SPRINGFIELD
Springfield TYPE OF WORK: Duplex
REQUIRED PARKING
Total: 4
4 Handicapped:
Yes Compact: .
39.70 \)~'t.
, ~\\~ ~ ~'V\
a.'\:." ~\ ,-
Subdivision Not Accepted I PUDLn.. lI,lPROVEMENTS I c.'t'\>'" o~\l.~ 'f.'V\l.
.. ~\.\..~... S' ",l;\~S)
Street Improvements: . F II I d ,I'c.', -< c..\'\ (.1 ilIk,v"tre:
" . u v mprove. ;\,V~ ~" ~ ~... ,,\\~~'"
Storm Sewer Available:.... Yes \\~, ,\>x.'?\ x.'i) \)~ ,'9dWnspoutsmrains:
Special Instruction: Storm drainage to weep hole in cl!'ril~\\\)\l.\-C ~x.'i) 'V~\l.''V'i).
~\) ~x.~ ~ y
Notes: No hook-up to any public infrastructure until SUbdi~~Ib~n accepted by the City
~~~
TYPE OF USE:
PROJECT DESCRIPTION: willowbrook subd lot 1 - Duplex
Owner: GYANENDRA PRASAD
Address: 4260 DAISY ST SPRINGFIELD OR 97478
I CONTRACTOR INI!ORMA TION I
Me' 'i\l~\\\\\'i
Contractor ~eo.lJ O~ \O\\'fLicense
DVAN" ~"'" "",O<"'~'~''''i.2112 '
~J 'tlltce~u\la~f>.v. calii ~\}~ 'RjI911
~ ,~O~ou~\'\ 0' \\'\~ \~ Qf'?,;,790
S _ .~ ~_~o,eS _'e\e~~_av.~295
~~~'Z.~l ~~JNFORM:tTION I
\t\OI".'io>)~ ~~J. ~~\ - 2:"'7'
# of Units: ~'~r..9i~e ~eC#~ ?el
Primary Occupancy Group: ,t;R~e~'O~.lIB~'Bclg t of Structure
Secondary Occupancy Group: ~ C/lJ'" Type of Heat:
Primary Construction Type VN Water Type:
Secondary Construction Type: Range Type:
# of Bedrooms: 2 Energy Path:
Sprinkltid Building:
Contractor Type
General
Electrical
Mechanical
Plumbing
1
16.00
Electric
Electric
Electric
Path 1
nla
I DEVELOPMElu mFORMATION I
Frontyard Setback:
Side 1 Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
18.00
6.00
11.00
10.00
3.00
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
Paee 1 of 4
New
Residential
Expiration Date
07/10/2005
06/21/2008
12/23/2005
01/14/2006
Phone
541-726-2960
541-995-4757
541-747-7445
541-741-3553
Lot Size:
Sq Ft 1st Floor: 900
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport 216
Sq Ft Other:
Occupant Load:
Curbside 5'
Curb and Gutter
.
,j
1)
10/IV( r~
\ -rv-
~~ <1"
J..-1Jfv' el~~~ b
r0
c
,
'-'1
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... .
. I ~I
.
"
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Description
Dwellines
Garaee
Tvpe of Construction
V Wood Frame
Garaee
Fee Description
Plan Review Residential
-Mechanical Issuance Fee--
+ 10% Administrative Fee
+ 7% State Surcharge
2 Baths One or Two Family
Addressing Assignment
Building Permit
Curbcut Permit
Dryer Vent
Exhaust Hoods
Plan Review Major - Planning
PW Mult Disc - 2nd Permit
Residence Wiring 1000 Sq Ft'
Residence Wiring Ea AddU 500
Sanitary Sewer - Improvement
Sanitary Sewer - Reimbursement
SDC MWMC Administration
SDC MWMC Improvement
SDC MWMC Reimbursement
SDC Sanitary/Storm Admin
SDC Transpo Admin
SDC Transpo Improvement
SDC Transpo Reimbursement
Sidewalk Permit
Storm Drainage Impervious Area
Vent Fan
Willamalane Attached (duplex)
Total Amount Paid
Initial Review
Plannine Review
09/15/2004
09/15/2004
.
I Valuation Descrintion I
5 Per Sq Ft
or multiplier
592.40
524.30
Square Footage
or Bid Amount
1,800.00
432.00
Total Value of Project
li'pp<. P'\ilLI
Amount Paid
$530.34
$10.00
$162.79
5113.95
$508.00
$62.00
$815.90
575.00
$12.00
$18.00
$103.00
$-30.00
. $212.00
$38.00
$612.52
$817.36
510.00
$1,730.62
$164.06
$181.51
$135.46
$1,544.98
$350.26
$75.00
$1,100.50
$24.00
51,848.00
511,225.25
Date Paid
9/14/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
10/7/04
I Plan Reviews I
09/15/2004
09/27/2004
APP SKG
APP TAJ
Paee 2 of 4
.
Lit 'f OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2004-01136
ISSUED: 10/07/2004
APPLIED: 09/14/2004
EXPIRES: 04/07/2005
VALUE: $ 176,817,00
Value
Date Calculated
5166,320.00
$10,497.60
$176,817.60
09/14/2004
09/14/2004
Receipt Number
1200400000000001345
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
1200400000000001445
.
.
CITY OF :srK11~ul'1~L1J
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-37691nspectlon Line
Building/Combination Permit
PERMIT NO: COM2004-01136 .
ISSUED: 10/07/2004
APPLIED: 09/14/2004
EXPIRES: 04/07/2005
VALUE: $ 176,817.00
Puhlic Works Review
09/15/2004 09/24/2004 APP CS 9/24/2004 - storm drainage shall be
directed to curb via weep hole. No
hookup to public facilities until
subdivision has been accepted by
City. CS
09/15/2004 10/0112004 OK RJB
, Structural Review
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 ~rrllurprl T~
. Curbcut - Standard: After forms are erected but prior to placement of concrete.
Sidewalk - Curbside: After forms are erected but prior to placement of concrete.
Vfer Electrical Ground: Install ground rod at footing and call for inspection In conjunction with footing andlor
foundation inspection.
Footing: After trenches are excavated.
Slab: To be made after all inslab building service equipment, conduit piping and other equipment items are in
place but prior to concrete.
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.
Walllnsulation: Prior to cover.
Ceiling Insulation: Prior to cover.
Drywall: Prior to taping.
Firewall: Located and constructed according to plans.
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.
Vnderslab Plumbing: Prior to filling the trencb and including required testing.
Rough Plumbing: Prior to cover and including required testing. .
Water Line: Prior to filling trench and including required testing.
Sanitary Sewer Line: Prior to filling trencb and including required testing.
Storm Sewer Line: Prior to filling trench.
Final Plumbing: When all plumbing work is complete.
Rough Mechanical: Prior to Cover
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.
Pa!!e30f4
.
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: COM2004-01136
ISSUED: 10/07/2004
APPLIED: 09/14/2004
EXPIRES: 04/07/2005
VALUE: $ 176,817.00
By signature, I state and agree, that 1 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 OCCVP ANCY will be made of any structure without permission of the Community Services Division, Building Safety.
I further certify that only contractors and employees wbo 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 during construction.
k.AO-A_L 'zI/~~/
. / ~,/
Owner or Contractors S' ature
Pa!!e 4 of 4
/tJ-1-tJ~
Date
,225 Fifth Street
Spriligfield, Oregon 97477
541-726-3759 Phone
.
Iii~
,
Job/Journal Number
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-0 1136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
COM2004-01136
Payments:
Type of Payment
Check
10/7/2004
RECEIPT #:
.ty of Springfield Official Receipt
Wevelopment Services Department
Public Works Department
1200400000000001445
Date: 10/07/2004
Description
Addressing Assignment
Willamalane Attached (duplex)
Residence Wiring 1000 Sq Ft
Residence Wiring Ea Addtl 500
Sidewalk Permit
Corbcut Permit
PW Mull 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 Sanitary/Storm Admin
SDC Transpo Admin
Plan Review Major - Planning
Building Permit
2 Baths One or Two Family
Vent Fan
Exhaust Hoods
Dryer Vent
-Mechanical Issuance Fee-
+ 7% State Surcharge
+ 10% Administrative Fee
Paid By
DUANE KNIGHTS
Received By
djb
Page lofl
Item Total:
Check Number Authorization
Batch Number Number How Received
5273
In Person
Payment Total:
1:29:30PM
Amount Due
62.00
1,848.00
212.00
38,00
75.00
75.00
(30.00)
1,100.50
817.36
612,52
350,26
1,544,98
164,06
1,730,62
10.00
181.51
135.46
103.00
815.90
508.00
24.00
18.00
12.00
10.00
113.95
162.79
$10,694.91
Amount Paid
$10,694.91
$10,694.91
CITY OF alNGFIELD SYSTEMS DEVELOPME~ORKSHEET
JOURNAL OR JOB NUMBER:
N'AMEORCOMPANY:
LOCATION:
TAX LOT NUMBER:
DEVELOPMENT TYPE:
NEW DWELLING UNITS
COM2004-01136
Prasad
196 Kaylee Ct 198
1703271 I TL03000
DUPLEX
2 BUILDING SIZE (SF; 1800
LOT SIZE (SF):
5622
Vl
u.l
Cl
o
U
~
u.l
E-<
Vl
a
~
L STORM DRAINAGE
DIRECT RUNOFF TO CITY STORM SYSTEM
I IMPERVIOUS S.F. x I COST PER S.F. I I CHARGE I
I 3550.00 1 $0.3 10 I = $1.100.50
RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS
I IMPERVIOUS S.F. J x I COST PER S.F. I x I DISCOUNT RATE I I
I 0.00 1 I $0.3 10 I I 50% I ~ I
ITEM 1 TOTAL - STORM DRAINAGE SDC $1,100.50 I
2 SANITARY SEWER -CITY
DISCOUNT
$0.00
$1,100.50
1070
A. REIMBURSEMENT COST:
I NUMBER OF DFU's I x COST PER DFU
I 34 $24,04 $817.36 11091
8. IMPROVEMENT COST: I
I NUMBER OF DFU's I x
I 34 $18.28 $621.52 11092
ITEM 2 TOTAL - CITY SANIT ARV SEWER SDC = I $1,438.88 I
_.. n__
-----,.---------".-
3. TRANSPORTATION
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 2 I I $18.30 I 1.00 I $350.26 1093
8. IMPROVEMENT COST:
I ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEWTRIPFACTORI
I 9.57 I I 2 I I $80.72 I 1.00 I $1,544.98 1094
ITEM 3 TOTAL - TRANSPORT A nON SDC = , 51,895.24
4. SANITARY SEWER - MWMC
A. REIMBURSEMENT COST:
INUMBER OF FEU's I x ICOST PER FEU
I ,
2 I I $82.03 = $164.06 11054
8. IMPROVEMENT COST: I
INUMBER OF FEU's I x ICOST PER FEU
I 2 I I $865.31 = $1,730.62 1055
MWMC CREDIT IF APPLICABLE (SEE REVERSE) SO.OO I 1054
MWMC ADMINISTRATIVE FEE $10.00 J056
ITEM 4 TOTAL - MWMC SANIT ARV SEWER SDC = , $1,904.68
SUBTOTAL (ADD ITEMS 1,2,3, & 4) ~ , $6,339.30 J
~ ADMINISTRATIVE FEE:
I SUBTOTAL x I ADM, FEE RATE I~ CHARGE I
I $6.339.30 I 5% I $316.97
,
TOTAL SANITARY ADMINISTRATION FEE: 181.51 1079
TOTAL TRANSPORTATION ADMINISTRATION FEE: $135.~ 1078
Matt Stouder 9/24/2004 TOTAL SDC CHARGES =, $6,656.27
PREPARED BY DATE
I . .
DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE
NUMBER OF NEW FixTuREs x UNIT EQUlV ALENf - DRAINAGE FIXTURE UNITS I
(Nom FOR REMODELS. CALCULATE ONLY THE NET ADDmONAL FIXTURES)
NO. OF FIXTURES DRAINAGE
UNIT FIXTURE
FIXTURE TYPE NEW OLD EQUIVALENT UNITS
BATHTUB 2 0 3 = 6 -,
DRINKING FOUNTAJN 0 0 1 = 0 I
FLOOR DRAIN 0 0 3 = 0 I
INTERCEPTORS FOR GREASE / OIL / SOLIDS / ETC. 0 0 3 = 0 I
INTERCEPTORS FOR SAND / AUTO WASH / ETC. 0 0 6 = 0 I
LAUNDRY TUB 0 0 2 = 0 I
CLOTHESW ASHER / MOP SINK 2 0 3 = 6 I
CLOTHESWASHER - 3 OR MORE rEA) 0 0 6 = 0 I
MOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 I
RECEPTOR FOR REFRlG / WATER ST A llON / ETC. 0 0 1 = 0
RECEPTOR FOR COM. SINK / DISHWASHER / ETC. 0 0 3 = 0 I
SHOWER, SINGLE STALL 0 0 2 = 0 I
SHOWER, GANG (NUMBER OF HEADSl. 0 0 2 = 0 I
ISINK: COMMERCIAURESlDENTIAL KITCHEN 2 0 3 = 6 I
ISINK: COMMERCIAL BAR 0 0 2 = 0 I
I SINK: WASH BASINIDOUBLE LAVATORY 0 0 2 = 0 I
ISINK: SINGLE LAVATORYIRESlDENTIAL BAR 4 0 1 = 4 I
I URINAL. STALL! WALL 0 0 5 = 0 I
ITOILET. PUBLIC INSTALLATION 0 0 6 = 0 I
ITOILET. PRIVATE INSTALLATION 4 0 3 = 12
MISCELLANEOUS DFU TYPE NUMBER OF EDU'S
20 = 0
TOTAL DRAINAGE FIXTURE UNITS 34
~ .EDU (Equivalent Dwelling Unit) is a discharge equivalent to a single family dwelling unit (20 DJ:Ys) set 81167 pllons per day
MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE
----,
YEAR
ANNEXED
CREDIT RATE/$I,OOO III
ASSESSED V ALUE ~
$5.29 -
$5.29
$5.19
$5.12
$4,98
$4.80
$4.63
$4.40
$4.07
$3,67
$3.22
$2,73
$2,25
$1.80
$1.59
$1.45
$1.25
$1,09
$0.92
$0.72
$0,48
$0.28
$0,09
$0.05
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
IS LAND ELG18LE FOR ANNEXATION CREDIT?
(Enter I for Yes, 2 for No)
IS IMPROVEMENT ELGIBLE FOR ANNEX. CREDIT?
(Enter I for Yes, 2 for No)
BASE YEAR
2
o
1979 ;,
,
CREDIT FOR LAND (IF APPLICABLE)
VALUE / 1000 CREDIT RATE
SO.OO x S5.29 ~ ,
SO.OO
CREDIT FOR IMPROVEMENT (IF AFrER ANNEXA llON)
VALUE/1000 CREDIT RATE
$0.00 x $5.29
o
TOTAL MWMC CREDIT
SO,OO
=
fJ
i(4ij
225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . F~~~26-3689
ELECTRJCALPERMIT APPLICATION _ ) ~ i:O,o~/";,,.9.o, .
CityJobNumberc.oWlW04_0/l3b Date 9//)"'"""/~'i>~,_ <?; <1o~~%~/~
f ." _"",....., q?,.~ _, ~Ol..$.r{".
1. UJi(ie;1:Pif)N<bEJiNSTXi!i?;(ij;jO~M . 3. t!e@Mi>~" Yo d " -; r~" ,~
Ii; ...",,, ".., . r, .".., .." ,.~, . ,~ . , " .,.., :;.f"
I '7 b /J 9 'it /CAy J~ C,.; ~.9"'" ',.t(" 'R ',O$~/~;:/''$'
A iN''''R'"'d'"'r'I,..r~",~ _~'''''?~
LE~~~~C~~~ C> JCTOC> 'se~~ 1:;U:~a = m · 0"" '~" ~~$I 00
JOB DESCRIPTION 1000 sq. ft. or less
Each additional 500 sq. ft. or '),.,. ,
DlA'Pt.-Ex portion thereof .l.-"$19.00
z,2
3%
Permits are non-transferable and expire If work is Each Manufact'd Home or
not started wltbln 180 days of issuance or if work is Modular Dwelling Service or
Suspended for 180 days. Feeder
2 (f'eONrFKAt:tORliNsiJ;4:i~T!4/fiii!>'M.(j~ .~.~. B. IiI'Se~i~~'~Ee"#<iers {Ii'ttMl'iio~,'Wiimtrfih~~R~i~~ii~:li..~
. ~....~,-:;;;:.-itil.il"".,Ii.->"""""---::'-";Wr_ _ ~ 1I;,":'~~1 . -- " " .'\,.....,.,11. ,lJ'j'.
Electrical Contractor tfl.\f ml1..r\ r:\ Fe 'L Ll\c 200 Amps or less $ 63.00
q, I, 'li \~-, , '201 Amps to 400 Amps . c ,.0U '':":.. $ 75,00
Address '-Il6\ lLY1\ww U~ 401 Amps to 600 Amp~.'leo.u'I~-;'~ 1j\\';~t\$125.00
J \-0." Ole... e' ,- ,
. J.:. (I~ (\d\C II~ 601 Amps to 1000lAmps\\e l:',eS _ ",C$.J'63,00
City \ J \'\('110)'\ \,,,\pho e VI VI (\ "...D l ~~~\ t Q.Oo'A,lwe~o~ ~e IU\0~P.~ 9~"',^~375.00
",",\,.Reconnest:only (."\,\\0 ou9,'\\ . .",e \V'.'(\~50.00
'" ..,IU"" ell'{o ,,\,\\1 'so. ''''~
I) 1'\/ c:.. ~"'.. .r" ...,,~v _^,e ~\^\e\" .', II
Supervisor License Number (){ nl JlO ~ \~{\\krgi~.~a.~~~~~~~~~ers ~'.' .'.. . ;. \', :,,\
l \ -() ~ Op..\-I_~~,\ ~e.'j,;II\el. "~~ U\' I')?lAA).
Expiration Date 0 - - I ,II ,!nstaJIation,rAlteratloli'Or ReloC'atlim
Ie) Qv~- " 9,\', ,\\e V. QIJ--
\C-.. \ n \ \ 20Q,A'i.;,dr,le~~p.( is ,\.'0
- J -\ 20.I'Amps to:400 Amps
1cJ ... 1. \ - b ~ 401 Amps to 600 Amps
Over 600 Amps or 1000 Volts see "BOO above,
D. . B'rlfiptli'~~ircuitS I I
$50.00
Constr. Contr. Number
$ 50.00
$ 69,00
$100,00
Expiration Date
Signature of Supervising Electrician
, ".j' _ . ~~ <;l '.' .... ,
. .,11"". ,~,,~ >;",~~l' 1. ..~~AS"" .r)&;~,.' 'O)~"'J
~-~
Owners Name 6-YI4-.~gdrA Q.-,.4-S,4-c!
I
4ZbD "bA-1 S;r
City S? 1':=' U
New Alteration or Extension Per Panel
One Circuit
Each Additional Circuit or with
E. s:;.;~;;~~~:t ., ';~~~~1'ii~f~jj~):~rb~i~ilil~ii6~.
- ~\.- ~ I'\~
Pump or irrig~~ ~\.-~ 'V Yo" $ 50,00
SignlOu~t1e b~ii~ ';:)~~ $ 50.00
OWNER INST ALLA nON ~\f\.J~' ~~~r&~~~tial $ 25.00
The installation is being made on property [own whiClj\<:) S ~\.-\'E~t~'E~\,g~€~merclal $ 45.00
IS not.ntended for sale, lease or rent. "\~'~Iln<>;;.~~I~,r.Ic"-Jit'imlt Inspection Fee Is 545.00 + Surebarges
~\) 4Ar, . ,:I; ,~" ..,.,. ;tj'R ",., -,'.
Owners Signature: ~4<) . T:A'L OEJ\4'BO,VE . , ',' . ':F' 2- 5'0
~ 7% State Surcharge 17 )0
10% Administrative Fee Z. s- 0 0
27Z~
$ 43.00
Address
Phone
Inspection Request: 726-3769
TOTAL
Shared Drive(T:)lBuilding FonnsIElectrical Permit Application 1.Q3.doc