HomeMy WebLinkAboutPermit Building 1992-10-21
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RESIDENTIAL
PERMIT APPLICATION
Inspections: 726.3769
Office: 726.3759
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1S1/,,(Pn100
2'7 /~
11- ltl ~ BLOCK'
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LOCATION OF PROPOSED WORK:
ASSESSORS MAP: /713 '2,
LOT'
OWNER:
ADDRESS:
CITY:
JIll d ",{w L,)YV'<>V
STATE: -illf/{>
DESCRIBE WORK'
seA u,w hlll:'ihli..CV
-/-G-,.,..P- ~ 'I' hJ -:;0 I
NEW'/'
ADDITION
REMODEL
ELECTRICAL'
DEMOLISH OTHER
.
5'2/4'~r'n
f
JOB NUMBER
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225 Fifth Streel
Springfield, Oregon 97477
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TAX LO-r.
-1~t17'J
SUBDIVISION'
PHONE:
7d.6 ~o.S"c;7
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ZIP:
c>"]Ir 7' 7
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CONST.
CONTRACTOR'
EXPIRES
PHONE
- OFF\~~ - .. "
QUAD AREA: \R\\W LAND USE: \ '- ( FLOOD PLAIN: - K)
. OF BLDGS: l . OF UNITS: J ZONING CODE: ~
~I CONSTR. TYPE:_AJ
OCCY GROUP: . OF BDRMS'
. OF STORIES' HEAT SOURCE: tE SECONDARY HEAT:
r..J l'~ , \AA( )
WATER HEATER: RANG~' SQUARE FOOTAGE:
CONTRACTOR'S NAME ADDRESS
GENERAL:_llff"lt.....k\.e._C\~rc~ /Q..5/) M",,, ,\r S->O",-,..,.~
PLUMBING:_C-V"1 L_b",""""" .,.:._. . 7'11-Koob I~() S' 7'31-"- ~VV(ch..,j,rzl:::"
MECHANICAL: ^ .1 \..'J\.C'i.L0() \'(\ ~~~p,\J<?\~?-F' ,( n q,"~,
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To request an Inspection, you musl call 726.3769. This Is a 24 hour recording. All Inspections requesied'before 7:00 a.m, will be
made tho same working day. Inspections requested after 7:00 a.m. will be made the following work day. .
REQUIRED INSPECTIONS
o Temporary ElectrIc
o SlIe Inspection - To be made
after excavation, but prior to
setting forms.
o Underslab Plumblng/Electrlcall
Mechanical - PrIor to cover.
o Footing - After trenches are
excavated.
o Masonry - Steel location, bond
beams, grouting.
o Foundation - After forms are
erected but prior to concrete
placement.
o Underground Plumbing - Prior
10 filling trench.
o Underfloor Plumbing/Mechanical
_ Prior to Insulation or decking.
o Post and Beam - Prior to floor
Insulation or decking,
o Floor Insulation - Prior to
dacklng, .
~ Sanitary Sewer - Prior to filling
'-P trench. .
o Storm Sower - Prior to 111 ling
trench.
""-~ Waler Llno - PrIor to filling
~ trench.
o Rough Plumbing - Prior to
cover.
o Rough Mechanical - Prior to
cover.
o Rough Electrical - Prior to
cover.
o Electrical Service - Must be
approved to obtaIn permanent
eleclrlcal power.
o Fireplace - Prior to facIng
materials and framing Insp.
o Framing - Prior to cover.
o Wail/Ceiling Insulation - Prior to
cover.
o Drywall - Prior to taping,
. , . . ..,. "...h/./>...
o Wood Stove - After In'stallatlo~. .
.."
o Inaert - After fireplace approval
and Installation of unit ,.
O .", , .
Curbcut,& Approach - After
forms are erected but prior to
placement of concrete.
o Sidewalk & Driveway -After
excavation Is complete, forms
and sub.base material In place.
o Fence - When completed,
. .' , ., ': ~ .' 'j..
o Slr.eet.1l"e~s - When all requlied
trees are planted. , .
o Final Plumbing - Whan all
plumbing work Is comple!.e.
o Final Electrical - When all
electrical work Is complete.
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o Flnsl Mechanical - When all
mechanical work Is complete.
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o Final Building - When all
required Inspections have been
approved and building Is
completed.
o Other
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MOBILE HOME INSPECTIONS
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~.'. 'BIOCkli;g[and':Set,UP - When all
;.~ ~bI07,~~.!:,gil.SI~c;Orr;~lete. '
5&,' pi~iJ~~'6o~n'e~uon", - 'w~en
~.tlori""e,:~as.,b~en connected to
~ ;~waterC~lOd"sewer.. .
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~.Electrli:al ,con'neetlon - When'
. 'blocking, set,up,.arid plumbing
, . ~~Inspectlons' have', been:npproved
, and the:hoiTjels~connected to
the serVice panel: ... "
~';"'nai ......Aft~~,a"..re%ulred .
LiI)('~speotfons.,iare\'app'roved ?ahd
..,_,"- '.--~'"._'-~ ~., ~..~,l<\,
., '. porcheai..sklrllng'I,d~9~s.' a~d .
::"ventlng .h'avEi:bee'mlnstalled:' l
Lot faces:
Lot ~ype .'
Interior
Lot sq. ftg.
Lot coverage
.'
C6rner
Topography
Total height
Panhandle
Cul.de-sac
BUILDING PERMIT.
I . ,~.: ','
ITEM ' SO, FT:.
...
,X $/SO.' FT.
Main
< '
Garage
CfMN\tU\uQ
Carport
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l~ THE PROPOSED WORK IN THE 1
-JISTORICAL DISTRICT, OR ON .....' II
THE HISTORICAL REGISTER?
If yes, this appllcallon must be signed
and approved by tile Historical
Coordinator prior to permit Issuance.
Setbacks.
I P.L, 'HSE' GAR' ACC I
.I N . I
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VALUE
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APPROVED:
.BUILDING VALUE, PLAN CHECK
'ANQBUILDING PERMIT
This permit Is granted onllle express condlllon thai tile said
constructIon shall, In all respects, conform to the Ordinance
adopted by the City of Springfield, including the
Development Code, regulating the construction and U50 of
buildings, and may be suspended or revoked at any tlmo
upon violation of any proVisions of said ordinances.
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Plan Check Fee:
Date Paid:
Total Value OJ~.,p)D
Receipt Numbcl':_
Building Permll Fee
~~ Received By:
State Surcharge
Total Fee (A) Plans Reviewed By Dale
. SYSTEMS DEV~LOPMENT':CHARGE~DCk.r--
(B) 09LP~
PLUMBING PERMIT
ITEM
Fixtures
Residential Bath(s)
Sanitary Sewer
N'
FT.
Water
FT,
Storm Sewer
FT.
Mobile Home
Plumbing Permit
State Surcharge
Total Charge
(C)
MECHANICAL PERMIT
Furnace
Exhaust Hood
Vent Fan
N'
Wood StovellnserllFlreplace Unit
Dryer Vent
Mechanical Permit
Issuance
State Surcharge
Total Permit
(D)
MISCELLANEOUS PERMITS
Mobile Home
State Issuance
State Surcharge
Sidewalk
II
Curbcut
ft
Domolltion
State Surcharge
Tolal Miscellaneous Permits (E)
TOTAL AMOUNT DUE-(excludlng electrical)
(A, B, C, 0, and E Com-OIllt;lUI
FEE
A,c:<"CXJ
A:=5.CO
,~,ou
12~a.>
3.~5
LoB~
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Systems Development Charge Is due on all undeveloped
properties within 010 City limits which are being Improved.
ADDITIONAL COMMENTS
By signature, I stale and agree, that I have carefully examined
the completed applicatlon and do hereby certify that all
Information hereon Is true and correct, and I further certHy
that any and all work performed shall be done In accordance
with the Ordinances of tile City of Springfield. and the Laws
of the State of Oregon pertaining to tho work descrIbed
herein, and that NO OCCUPANCY will be made of any
structure without permissIon of the Building Safety Division.
I further certify Olat only contractors and employees who
are In compliance with ORS 701.055 will be used on thIs
project.
I further agree to ensure tllat all required Inspections are
requested at the proper time, that each address Is readable
from the street, that the permit card 15 located at tho front
of the property, and the approved set of plans will remain
on the site at a/l limos during construction.
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Date _/~;:J{L.C;
VALIDATION:
RECEIPT NUrR'l~ ,. . -~
DATE PAID JU-c9..- - - _
AMOUNT FlE~m __ _ ()5.{o
RECEIVED 'iA~J
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."mlt No, -3B 14to ~
Address: &L~ thew A(} :#cJ01
Issued bya/.J'{l-~ Date: 10 ,2(.9~~
FOR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued, This state.
ment is required for residential building, electrical, mechanical, and plumbing
permits, Licensed Architect and Engineer applicants, exempt from registration
under ORS 701,010(7), need not submit this statement. This statement will be
filed with the permit.
Fill in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 3B:
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1, I ......... I I own, reside in, or will reside in the completed structure,
2. I
I I understand that I must register as a construction contractor if the structure is sold
./ or offered for sale before % upon.completion. 1---.. ~
v I My general contractor is ~ vl\(\ ~ f'\r) D.t\ " )Q (~)\ QJ) )
Contractor registration number /\~:\~ q
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
3, A.I
OR
3, B,I
I I will be my own general contractor,
If I hire subcontractors, I will hire only subcontractors registered with the Construe.
tion Contractors Board, If I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor,
I hereby certify that the above Information is correct and that I have read and understand
the Information Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
10/~//9..2-'
Date I ( -
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
~
INFOFtATION NOTICE TO PROPERTY OtNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
..' ":..
NOTE: 'This Information Notice to Property Owners About Construction Responsibilities
. -.... .
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
_ passE;!d .bytt)e 1989 Oregon Legislature,
,
If you are acting as your own contractor to construct a new home or make a substantial improvement to an
existing structure, you can prevent many problems by being aware of the following responsibilities and areas
of concern,
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction or improvement of a residential structure, you will, in most instances, be ruled to be an
"employer" and the people you hire will be "employees", As the employer, you must comply with the following:
Oregon's Withholding Tax Law: As 'aM employer, you must withhold income taxes from employee wages at
the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the
tax from your employees, For more information, call the Oregon Department of Revenue at 378-3390,
Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all employees, For more information, call the Oregon Employment Division DHR
at 378-3224.
Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation
Law, and must.obtain workers' compensation, insurance .for your employees. If you fail to obtain workers'
compensation insurance,. you' may be subjedto penJalties.andwill be liable for all claim costs if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 373-7434,
t . .1. -
U,S, Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages,
You will be liable for the tax payment even if you didn't actually 'tIithhold the tax. For more information, call
the Internal Revenue Service at 221-3960, .
OTHER RESPONSIBILITIES AND AREAS OF CONCERN: .
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requirements that may be brought to your atteption through inspections,
Liability and Property Damage Insurance: Contact your insurance agent to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees: Make sure you have sufficient time to supervise you'r employees,
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections,
If you have additional questions, write to:
Construction Contractors Board
700 Summer SI. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
0244J 10/24/89
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DEVELOPMENT SERVICES
PUBLIC WORKS
METROPOLITAN WASTEWATER MANAGEMENT
225 FIFTH STREET
SPRINGFIELD. OR 97477
(503) 726,3753
MOBILE HOME AND MP~UFACTURED HOME AGREEMENT
UNITS TO BE PLhCED IN A PARK
As required by the City of Springfield Development Code and/or the State of
Oregon, I understand and agree, as sho.n by my signature on this form, that .ith
~'h Wf.!?'.,'a'-"hthe at. tach,<sl. ,l/AAts for a home to be located at
:-II ) n . Vll(lJ ::trDJJ...1::1 ' Springfield, Oregon, Ci ty Job Number
_1:::V4Lpll} I .ill meet or exceed the belov listed minimum setbacks.
Home Se t ba cks
10 feet from a park building
20 feet from any public street
5 feet from any rear space line or interior space line
5 feet from the edge of a park s tree t
2 feet from the interior edge of a park side.alk
hccessory Structure Setbacks
10 feet from a park building
20 feet from any public street
5 feet from the edge of a park street
2 feet from the interior edge of a park side.alk
3 feet from an interior space line or rear space line
I further state, by my signature below, that I have been provided with the
follo~ing information:
Manufactured Home Blocking Requirements
Minimum Requirements for Permanent Steps
- Electrical Connection
si2~ jJt
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Date I
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CITY OF S.ItlGFIELD SYSTEI1S OEVElOrl'l..T
WORKSHEET ·
(C0I111ERCIAL r.. RESIDENTIAL)
CHARGE
NM-IE' O[t COIWAN\': J,:~Lo.~J"_.;.._,bQMt>. t'A.(}.& L'=.fr'- ~o WI I::. . PA-~
LOCATION: SDC. -t;; I?~ PA-Il) WHV.IJ MOP.->II.-l2:. \-krv\S I":> Mo\ltGDI'-.\.
DEVELOpl'lENT TYPE:
[JUILOING SIZE:
1. STOR/.l ORA IHAGE
.LOT S rzC
,SQ. Ft.
Il'lPERVIOUS SQ. n. . X SO.lllG rER SQ. Fr.
(See ,Reverse For Runoff Coefficients If Actual Imperv. Area
Is 0-
Is Unknol-ln)
2. SANITARY SHIER-CITY
NO. Or- rr-u's 1<+ . X S311.55 PER rFU
(See Reverse To Oetennine Total rrU'S)
Is ??9 I~ I
3. rr..r,rlSf'ORTr\TlJ];I.
rlo Or: UillTS X T!m' RJ\TE X COST rER TRIr
x
v "'~0~ r.,
.\ ..)-".,1'..'. L)_
k 'z/1. "7 0.;:.1
s
s --
s 1 (,,;7. 1~
j, .~l!l..~ ::: S3S3.Gl
----.--
v
X S333.i:il
To Oeteroine Trip Rates)
SUl3TOTAl'(ADD ITE11S 1,2,
& 3)
(See Attachment C
4. ADIHlHSTRAT!VE FEES
'[lASE CHARGE (SUBTOTAL ABOVE) X ;05'
Is "7'OIj. I
TOT,\L-CITY SDC. .S €CO ~
5. . SANITARY SEWER-H'..!HC
....:"'..:..:'.:.~.'; .:.,-. ;:.~-.;- ,.,..,.,' > . ." .
_~:.' '",;-o"iioOF PFU'S"'''I.f- c;"x 513.25 PER PFU.+ 510 1-lWI-IC ADMIN. .fEE S
, . .' +:iffEf;.!t~],;i:,~;:,.,~:,,~,';'.{;t::;.~~..;'-""':;"~'-;~-, <:<';- -- '.-
.~ ,__;' >,_.,(.",:;,:..-~(UsePFU.}otal Jrom Hell! ,2 ..~bove) .;: -: .
::;:':.~::,:,:,...::~_'~;~;{~"-f~~rii~::iF-~;-~Ei~itli~~kE-V~~SE; ~'....
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i:""S''-':};:' 'so~i~o~~~~~~~or II
I"IC,~
:~'I!~YHT'~~~,/'i'. ;
". "TOTAL-~~~'t'ib'h~ 1"1 c; ~ 1
TOTAL sac'~ qq (.. e
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CITY OF SiItlGFIELD SYSTEt-tS OEVELorr'lENT
WORKSHEET .
, . '(COHI1ERCI^L t. RESIDENTIAL)
CIIARGE Cf9 10- q (
*~~:
tWIE ort COIWAN\': J:to.~:L6.__~QMt>. t'A.fl.&L'=::.f.'- ~OWlI::.' Pl\~
LOCATIO/I: SDC. i;\?G P~HV.~ M Of':> I 1.-1C.\...I-orv\S I":> MO\JtG1>
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DEVELOPMENT TYPE:
[JUILDING SIZE:
.LOT SIZE"
,SQ. Ft.
1. STORl'l ORA WAGE
mrERVIOUS SQ. FT. X SD.ll3G rER SQ. Fr.
(See Reverse For Runoff Coefficients If Actual Imperv. Area
Is 0-
Is UnknO\m)
2. SANITARY SE~I[JZ-CnY
NO. OF rfU'S I'-J- X S38.55 rER Pi-U
(See Rcverse To Octenninc Total' rrU'S)
Is ??"I"~I
3. TRfdISPOlnr\TT.1}l1
f:O or UiIITS x Tim' RATE x COST PER TRIr
;, . c:,jl..r
X S3ES.Gl
Is '2.:2.";,0.::.1
x
X S3SS.Gl
s
-
v
X 5383.Gl
Odcroine Trip Rate:;)
SU[]TOTAL '(ADD
ITEI{S 1,2, & 3) S 1 (p 1.. 1~
(See Attachment C To
4. ADfHNISTRAT!VE FEES.
'[JASECHARGE' (SUBTOTAL ABOVE) X ;05 Is "7'OIj. I
TOT,\L-CiiY SJe s Seo ~.
.' i,:~.':;_~~g:;,:)io'~','OF. P.F~'S "'" J..J- '.n .,. x 513.25 PER PFU .+ 510 m:l-lC Ar'KIN. FEE s I"J c:; ~
,;_,;,:,?~;:~::::-,;;:,:~:)>..:.~:,,~:,~,,:,,:.,:;:~-:.."";/;c~,c.-~._;:~;::~<:;:.t:':::'.'",' '. . . '., . -"- '" '......... . .
"2;:;,;:~~:~~=:1:~ Use ,PFU.J oJ al _, F. rO,m J ~.:,~2 .A~O ve ) .' .... '_-";':'.:.~,~:..'._--'...:.:.:.,~'.:'.~','-:_._:'.. -.:,..'.~.....:_:~.'_~~.......::~.'.,-'......_;.,._;..:~,_:"..:::~'::._'
..~..;...:..,.:'.:.'.....'.;',..'...~.-':'.,:,_:.~._'.:.'..',.~:.::~.:.-.:.,.-'s:.:~.:"..~,....,~'...::.:,;....:,'.~~...-.:.;.:.:...,...:,.-:..:'....~......../ ......:-:..... .'
;-:~.~. ;'. _, .,'. : ", \ .-:..:'~.:~~:-...:.:~~: ~._', "~~-:_'~:~:~.::..:..=_:..:....;.~.:i::(:.:<~:'->:.-;t -....:,. ~:'--=-,.- .,,-- ~ _. .c- '_ ~ - ~ ._' .> <'
. ;.;. ;,,;;,;.,. :__HWI1C, CREDIT IF APPLICABLE (SEE REVERSE)
"c;.;;;:':'~';":?~::""""'!Ix."/i;' .. 'TOTAl-;"'~;~~ls 11 s ~ I
r...}{h/~\;:,',:,,;_.., . qKip [Jurdick . fl.. TOTAL SDC \ qq~ e
. .. ," .sac Coordinator d. ,',':-:,""-
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--~..:-~':.~~' .. . '. ..
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5. SANITMY SEWER-H\-II1C
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CITY OF
s.Ii.lnUGFIELD SYSTCl-1S OEVELOP/.IENT
. WORKSHEET .
(COIlllERCIAL I, RESIDENTIAL)
CllAnGE
NM-IEO[1 COIWAHI': J:Lo.~T.;.__.~Q}'J\t>. N:\.9.&l'::,f". ~OWlI::. 'PA-~
LOCATlOll:5DC -ro'7~_e:XJ.JL\01Hv"l M,op.?, I.-~. w.iJrv\~ I":> Mo\JtG" \ <....\ .
DEVELOpl'lG1T TYPE:
[JUILDING SIZE;
1. STORl'l ORA WAGE
LOT SIZE'
.SQ. Ft.
Il'lpERVIOUS SQ. n. X SO.IBG rER SQ. Fr.
(Sce Reverse For Runoff Coefficients 'If t,ctual Imperv. f,rcJ.
Is 0-
Is UnknOlin)
2. SANITARY SEWER-CITY
1:0. or rrv's I Lj. X $313.55 pm Pi-U
(Se~ Rcversc To Octcluinc Total' rrU'S)
Is ?,?q I~ I
~. JJYdL~J~D.1~T((iJ.rl'l_
NO Or: IJilITS X T!n,' lV-HE X COST PER TRII'
. l~'IL:
~: $322.C1
k 1/1- =;,0'::"1
v
x ~:::SS.Gl
i,
-----.------
-.'
(See Attacl:;nc:lt C To Ot2tcminc Trip RJ.tes)
SU[JTOTAL . (ADD ITEI-~.S 1,2, t, 3) S
v
.',
X S3S3_Gl
- ,
1~1..I;'"
4. ADIHlHSTRAT!VE FEE~
'OtlSE CHARGE' (SUBTOTAL ABOVE) X ~05 Is "7'OIj. I
--T" r--" ,-~,~ r r -'0",0
liJjl~.L-'_ll' '::~:'''' '.} 'CL,.. -
5. SANITARY SEWER-HWI'\C
,110. OF PFU'S
" I...f-
x 513.25 PER PFU .+ 5!0 l1WHC ADXIN. FEE S l"l C; ~
': -- .' .-.: .... . - ~ . -. ..::",.-
," .". ,". ..' _ ...u. '._ _' . .
. .': .~;>.'.:.:(Use PFU Tota.l F,:~,?.Item' 2 Above)
. '" -, .~ ~ :......- . .-:.. ...... . --;--, . ", :.",. -.--"~~'.' - ," .. '. .
~lWH~ CREDIT IF ArPLlCABLE (SEE REVERSE)
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.....G. Kip [Jurdick
SOC Coordinator
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CITY OF
5.' rlGFIELD SYSTG15 OEVELOPl.IENT
WORKSHEET .
(COMMERCIAL ~ RESIDENTIAL)
CIl^IIGE
!
tWl['OI( COIWAN\': J':to.~T.;.._lQ.0.0~.9.&L'=f:- ~o,,^1::. 'PA-~
LOCATlOtI: SDC. --r;;?.f_&-,.JL\01!:l~Mt)I"~\ L-lC:.t-I-orv\S I":> Mo\JtG" \ k.\ .
DEVELOPMENT TYPE:
I.
I
[JUILOING SIZE:
LOT SIZE'
SQ. F t.
1. STORr.1 ORA WAGE
I/-lpERVIOUS SQ. n. X SO - 18G rER SQ. Fr.
(See Reverse For Runoff Coefficients If Actual Imperv. Area
Is 0-
Is Unknwn)
2, SANITARY SE>IEIZ-CITY
1:0. a:: rEV'S I Lj- X $38.55 pm ,,:'v
(Sce Reverse To Oc~tcnninc Total rrU'S)
Is ??"1"~ I
:.. IC!iL~J~Q.nTDIJJr!.
. f;O Or- UUITS X T!~ril !0\TE X COST PER. TRIP
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I,s 1.."'2.";,0';' J
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x
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v X S3S3.Gl
(See Attach:nent C To Odemine Trip Rates)
SU[JTOTAL . (ADD
ITEI',S 1,2, t, 3) S
~ ,
'/101.. I;"
4. AOI-lTlHSTRAT!VE FEES
'[JASE CHARGE' (SUBTOTAL ABOVE) X ;05
Is "7'OIj. I
TOTr\L-CliY S0C
"'0
r ~C0 ~
5. SANITARY SEWER-H'..!I'IC
., . NO. OF PFU'S
. ',../-
x S13.25 PER rFU .+ S10 11I-1HC ADXltl. FEE S I ~ C; ~
-.. ...., ,..._~ .:.,
. ... "- ~.. . '".-.
<:'" ..'i(use PFU Total From lte~ 2 Above)
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. U Ki P Burdick
SDC Coordinator
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TOTAL -MW~lC SDC Is I ~ C) ~ J
Tl)TAL SDC S qq l" e_
HWMC CREDIT IF ArPLICABLE (SEE REVERSE)
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