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Home My WebLink AboutPermit Building 2004-10-28 . Lu f OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-0I169 ISSUED: 10/28/2004 APPLIED: 09/2112004 EXPIRES: 04/28/2005 VALUE: $ 5,000.00 -. Status Issued * 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line I SITE ADDRESS: 1141 LAUREL AVE ASSESSOR'S PARCEL NO.: 1802064200201 Springfield TYPE OF WORK: Manufactured Home on Private Lot New PROJECT DESCRIPTION: TYPE OF USE: New double-wide Manufactured Home - on septic system (Intends to use well water from parcel to the south as potable water supply) Overlay Dist: ~ 19\\lG(t\-ba~ge # St~~~. ~\i{~,: e~ 10\ le~ \'~~ 0 .~ l~fhel~[! eO e~ 6\l., O"-e~\lf\II~ ;Qt,€~a~~,\lo f.-e\lll\O"';~\ \l \. d a\ al.\\ . \lle\Q Ii '=Nb'~ e\101.\ ~\.."O sa\dO~. ;." no-"Oo-~~,,<<.)\\\\o" . ~'Plf~apV,i~~'FS\V~'" ~ltU ,..oll~ . ,"- . el....-' in ",d.- ~ ~'.'N.:uJ: . \\l01 \eS "'alO el.\\ "... palO :~\SilIewalk Type: .. \1'\ \lOu HI'll1 \l0 f.~1:p' :f. sal\n\)Ell DownspoutslDrains: Storm drainage to drjl.\ll . Owner: K1LE STEVEN D Address: PO BOX 7684 EUGENE OR 97401 -~li; .' Contractor Type General Electrical Plumbing . .,\\)~~ .f'\'I\.....r ~\.l' I CONTRACTORlNEORMii'i.JON I , I \\ l'e :-,..\.. tr ~S y..... ~\) \ Contractor i'" ,~;>\\~ ~~ "\'0 'rov..\)\:;~ License HARRIsq~ R.1,lS!?-~ ~~ ,S \>-'0 66447 ROBS EL~"~ J~;:(.\) \:;~ ~\:;\). 156678 HARRISON .!.\\e9...~..;I>~\!\q><(; 66447 c,~~I\~M[D1NG INFORMATION' I # of Stories: R-3 Height of Structure Type of Heat: Water Type: Range Type: Energy Path: Sprinkled Building: # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: VN Electric Electric Electric Path I nla 3 I DEVELO~MENT INFORMATION I Frontyard Setback: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: 47,00 85.00 45.00 15.00 5.00 Street Improvements: Storm Sewer Available: Special Instruction: Notes: .- . _, ~~,,\tF~..: Pa!!e I of4 Residential Expiration Date 05/07/2005 08/14/2005 05/0712005 Phone 541-689-7762 541-686-5444 541-689-7762 I Lot Size: Sq Ft 1st Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: 14,811 1,404 REQUIRED PARKING Total: 2 Handicapped: Compact: Drywell - Provide Drywell Engineering Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-37691nspection Line Description Tvpe of Construction . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-01l69 ISSUED: 10/28/2004 APPLIED: 09/21/2004 EXPIRES: 04/28/2005 VALUE: $ 5,000.00 I Valuati?" Deserintin" I $ Per Sq Ft or multiplier $1.00 $1.00 Foundation Onlv Use Bid Amount Manuf Home Manufactured Home Fee Description Plan Review Residential + 10% Administrative Fee + 7% State Surcharge Addressing Assignment Fixture Foundation Permit Manuf Home State Issuance Manufactured Home Conn - Plmb Manufactured Home Feeder Manufactured Home Placement Sanitary Sewer - 1st 50 Feet SDC Sanitary/Storm Admin SDC Transpo Admin SDC Transpo Improvement SDC Transpo Reimbursement Storm Drainage Impervious Area Storm Sewer - 1st 50 Feet Storm Sewer Each Addtll00' UGB Plan Rev MjlMin - Planning Water Line - Ist 50 Feet Willamalane Manuf Home Private Total Amount Paid Initial Review Plannin!! Review Plannin!! Review 09/24/2004 09/24/2004 10/20/2004 Square Footage or Bid Amount 5,000.00 45,000.00 Value Date Calculated $5,000.00 $45,000.00 $50,000.00 0912112004 09/21/2004 Total Value of Project Fpp< P~ilIJ Amount Paid $44.46 $48.64 $34.05 $31.00 $14.00 $68.40 $30.00 $45.00 $50.00 $160.00 $45.00 $11.28 $47.39 $772.49 $175.13 $225.68 $45,00 $14.00 $156.00 $45.00 $1,000.00 $3,062.52 . Date Paid Receipt Number 9/21104 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 10/28/04 1200400000000001375 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 1200400000000001529 I Plan Reviews , 09/23/2004 10/14/2004 10/20/2004 APP WE TAJ Needs access maintenance easement and easement for access to well. Spoke with Randy at Gooden-Harrison and told him that on 10/15. easements received Bnd OK APP T AJ Pa!!e 2 of4 . . CITY OF ~rKlI'il"<l.l!..L1J Building/Combination Permit PERMIT NO: COM2004-01169 ISSUED: 10/28/2004 APPLIED: 09/21/2004 EXPIRES: 04/28/2005 VALUE: $ 5,000.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Public Works Review 09/24/2004 . 10/04/2004 APP MS 10/04/2004 - No portion of the building or storm drains shall be place In the 45 foot private easement. Contacted the applicant, and he said the building and drain lines will be located out of the easement as per telephone conversation on 10/04/2004. - MS Structural Review 09/24/2004 09/30/2004 OK DLM 10/04/2004 - Including drywell information packet with plans, Drywell shall be located a minimum orIO feet from foundation. - MS Verify wi Public Works & Planning whether a access agreement & maintenance Agreement is required for access to the well water on the adjoining southerly property. Standard MH plan review comments were used for the permit, 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 Rponirrilnsnections I Ufer Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing andlor foundation inspection. Footing: After trenches are excavated. Manuf Home Set Up: When installation of all piers or stands is complete. Final Manuf Home Set Up: After all required inspections are requested and approved and porches, skirting, decks, venting, street address numbers, trees, driveway, etc. have been installed. Final Building: After all required inspections have been requested and approved and the huilding is complete. Undernoor Drain: Prior to cover or placement of concrete. Water Line: Prior to filling trench and including required testing. Line to Septic Tank: Prior to filling trench and required testing. Storm Sewer Line: Prior to filling trench. MH Electric: When blocklng, setup and plumbing inspections have been approved and the home is connected to the panel. Pa!!e30f4 . . CITY OF M'Kll~GFIELD Building/Combination Permit PERMIT NO: COM2004-01169 ISSUED: 10/28/2004 APPLIED: 09/21/2004 EXPIRES: 04/28/2005 VALUE: $ 5,000.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line 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 descrihed herein, 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, that each address is readable from the street,thY2t ~er 't car!f'is locat at the front of the property, and the approved set of plans will remain on the site at all times duri g c nst u tiori ~ U ~ "" -.. (()-LtrO,-! Owner or Contractors Signature ~ Date Pa!!e 4 of 4 ,225li'ifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 COM2004-01169 Payments: Type of Payment Check 10/28/2004 . alliL~! .,., . "--. '..' RECEIPT #: ~y of Springfield Official Receipt .velopment Services Department Public Works Department 1200400000000001529 Date: 10/28/2004 DescrIptIon Addressing Assignment WiIlamalane Manuf Home Private Manufactured Home Placement Manuf Home State Issuance Foundation Permit Sanitary Sewer - 1st 50 Feet Water Line - 1st 50 Feet Storm Sewer - 1st 50 Feet Storm Sewer Each Addtl 100' Manufactured Home Conn - Plmb Manufactured Home Feeder Fixture + 7% State Surcharge + 10% Administrative Fee Storm Drainage Impervious Area SDC Transpo Reimbursement SDC Transpo Improvement SDC SanitarylStorm Admin SDC Transpo Admin UGB Plan Rev MjlMin - Planning Paid By GOODEN HARRISON Received By djb Page I ofl Item Total: Check Number Authorization Batch Number Number How Received 9166 In Person Payment Total: 1 :3S:47PM Amount Due 31.00 1,000,00 160.00 30.00 68.40 45.00 45.00 45.00 14.00 45.00 50,00 14.00 34.05 48.64 225.68 175.13 772.49 11.28 47.39 156.00 $3,018.06 Amount Paid $3,018.06 $3,018.06 . MANUFACTURED HOME LAND USE AGREEMENT As required by the City of Springfield Development Code, I agree that with the approval of the attached. permits, one of the following manufactured homes will be placed at 1141. {..ALf./te-{, A V~ Springfield, Oregon, City Job Number ((J;It '2./JOf -(') 1/(,5. . ~ Type I Manufactured Home. A multi-sectional (double wide or wider) unit with an enclosed floor area of not less than 1,000 square feet, 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 constructed 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 roof mg. 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. /1 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 and/or 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 r~cording of any required partition, easemeni, improve\llent agreements, etc. . . Fiiiallot 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. . 'X- -/fl M Date vt... UJ -l.1_0Y '>< --- J_ ^ ~ Contractor Signature - ./ Date . ' ' JOURNAL OR JOB NUMBER: NAME OR COMPANY: LOCATION: TAX LOT NUMBER: DEVELOPMENT TYPE: NEW DWELLING UNITS CITY OF SINGFIELD SYSTEMS DEVELOPMEN&RKSHEET '1- IrFJ tJJ 10 10 U 10:: I~ rFJ a ~ COM2004-0 II 69 Martha Kile '1147 Laurel Ave 18020642 TL 00201 SINGLE FAMILY RESIDENCE I BUILDING SIZE (SF' o LOT SIZE (SF): 14811 I. STORM DRAINA.GE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. x I COST PER S.F. I CHARGE 0.00 I SO.31O = I $0.00 I RUNOFF ROUTED TO DR YWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S.F. I x I COST PER S.F. I x I DISCOUNT RATE I I I 1456.00 I SO.31O I 50% = I ITEM I TOTAL- STORM DRAINAGE SDC S225.68 I 7. SANITARY SEWER - CITY A. REIMBURSEMENT COST: I NUMBER OF DFU's I x I 20 I ITEM 2 TOTAL - CITY SANITARY SEWER SDC = I SO.OO J TRANSPORTATION A. REIMBURSEMENT COST: , ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEW TRIP FACTORI I 9.57 I I I S18.30 I 1.00 B. IMPROVEMENT COST: I ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEW TRIP FACTORI 9.57 I I I I S80.72 I 1.00 ITEM 3 TOTAL - TRANSPORTATION SDC = , S947.62 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL - MWMC SANITARY SEWER SDC = , SUBTOTAL (ADD ITEMS 1,2,3, & 4) ~ , 5. ADMINISTRATIVE FEE: B. IMPROVEMENT COST: I NUMBER OF DFU's I x I 20 I 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: INUMBER OF FEU's I x I I I B. IMPROVEMENT COST: INUMBER OF FEU's I x I I I DISCOUNT $225.68 S225.68 , 1070 COST PER DFU S24.04 SO.OO 11091 I 11092 ,I S18.28 SO.OO S175.13 I 1093 I S772.49 I 1094 I ICOST PER FEU . S82.03 = SO.OO 11054 I SO.OO I 1055 SO.OO 11054 SO.OO J11056 I ICOST PER FEU S865.31 = SO.OO SI,173.30 I SUBTOTAL I x ADM. FEE RATE I~ I SI.173.30 I 5% I TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: CHARGE S58.67 10/412004 11.28 1079 S47.39 111078 I = I $1,231.97 I I Matt Stouder TOTAL SDC CHARGES PREPARED BY DATE . . ' . DRAINAGE r 1A I URE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVALENT - DRAINAGE FIXTIJRE UNITS (NOTE: FOR REMODELS. CALCUl.A TE ONLY TIlE NET ADDmONAL FIXTIJRES) NO. OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUIVALENT UNITS I BATHTUB 1 0 3 = 3 I DRINKING FOUNTAIN 0 0 1 = 0 I FLOOR DRAIN 0 0 3 = 0 I INTERCEPTORS FOR GREASE lOlL 1 SOLIDS 1 ETC. 0 0 3 = 0 I INTERCEPTORS FOR SAND 1 AUTO WASH 1 ETC. 0 0 6 = 0 !LAUNDRY TUB 0 0 2 = 0 ICLOTHESWASHER/MOP SINK 1 0 3 = 3 ICLOTHESWASHER - 3 OR MORE (EA) 0 0 6 = 0 IMOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 I RECEPTOR FOR REFRlG 1 WATER STATION 1 ETC. 0 0 1 = 0 IRECEPTOR FOR COM. SINK 1 DISHWASHER 1 ETC. 0 0 3 = 0 ISHOWER. SINGLE STALL 1 0 2 = 2 ISHOWER. GANG (NYI\:IBER OF HEADS\. 0 0 2 = 0 ISINK: COMMERCIAURESIDENTIAL KITCHEN 1 0 3 = 3 ISINK: COMMERCIAL BAR 0 0 2 = 0 ISINK: WASH BASINIDOUBLE LAVATORY 1 0 2 = 2 ISINK: SINGLE LAVATORYIRESIDENTIAL BAR 1 0 1 = 1 iURINAL. STALL 1 WALL 0 0 5 = 0 ITOILET. PUBLIC INSTALLATION 0 0 6 = 0 ITOILET. PRIVATE INSTALLATION 2 0 3 = 6 MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 20 .EDU (Equivalent Dwelling Unit) is a discharge equivalent to a sinp:le family dwelliIlA unit (20 DFU's) set at 167 ~lons per day MWMC CREDIT CALCULA nON TABLE: BASED ON COUNTY ASSESSED VALUE YEAR CREDIT RATElS~ II ANNEXED ASSESSED VALUE IS LAND ELGIBLE FOR ANNEXATION CREDIT? 2 BEFORE 1979 . $5.29 (Enler I for Yes, 2 for No) I 1979 $5.29 IS IMPROVEMENT ELGIBLE FOR ANNEX. CREDIT? 0 1980 $5.19 (Enter I for Yes, 2 for No) II 1981 $5.12 BASE YEAR 1979 1982 $4.98 I 1983 $4.80 CREDIT FOR LAND (IF APPLICABLE) 1984 $4.63 .vALUE 11000 CREDIT RATE 1985 $4.40 SO.OO x S5.29 ~ , So. 00 I 1986 $4.07 I 1987 $3.67 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) I 1988 $3.22 VALUE 1 1000 CREDIT RATE 1989 $2.73 $0.00 x $5.29 0 I 1990 $2.25 1991 $1.80 1992 $1.59 TOTAL MWMC CREDIT = SO.OO 1993 $1.45 1994 $1.25 1995 $1.09 1996 $0.92 1997 $0.72 1998 $0.48 1999 $0.28 2000 $0.09 2001 $0.05 L I I I I I I i I I I I I , I I I I (I Sep-30-04 03:14P P.02 .......~I..."..!"'UIL.D 225 .'IFTH STREET. SPRINGFIELD, OR 97477 . I'H:(541)726.3753 ELECTRICAL PERMIT APPLICATrON Cit)' Job Number C0W17-00 4 - 0 t I b 7 Dale . FA-X: (541)726-3689 .. .....:.:.. t\:.,;:,. ~* ,." '''':;i. ',. lo-~rg;-Olf 3. Cor.fPu.'n FEE SCHEDULE B.l:"LOW .' . . h ~ -l.. 0.,. -O/, ," . ..... ~ ~ ~ .' .'. . A. ..NC\~.R.~'~d.~ntla~~~i'l<'1f,oMUIlI-F.IOII)'.p.rdw.llina uniL' . I:J."._ :( 0' <z ....0. Service lm'l~d ~ 0& "\.9"/ ~Gr. "0. is'., q.r 1000'q. f1.~les, "/~ 0" "'''6 $106.00 Each addilion;~8<! s ft.:y ">>"" '7)/.;... portion thereof U/^. \. & oS'^ O'~ ~ 19.00 d~"" ." ~ Permits 3n non-rrandt'rabJe and e~pire if work is Each }l.unufnc!'d !-Iom~ ..~"'? (I'Qc- /.,t~&t.: ,.-. ,. not sluted within 180 day~ ofiuuanct or irwork is Moduiar Dwelling Service r ~~ ~"6':::to~ 5 0 Su.speuded for 180 days. Fcedcr d $. "(lI..~- 2':'(;O;;'']:~~. NSTALL..4,n080NU' D. ~s,~~':i';.;io;F~.ders ~..!..,\SlIli.'io ~. Ie ~.... rR.IJ~~~~~: '. .,. .. . . . ..... s,..., , ~c, ~'1 ~?~. . Electrical Conll1lClor _ ~~rine, T X\Q.. 200 ,\ill?' or ~\)~O<' ~~,d'''' $ 63. C'\ n _ <Jh 201 Am' ~~1ii?'~e~"". $ 5.00 Address \/() \~-X LI'"";2J &'O'l~~,yn~~~,., () , $125.00 , 1I1~~' b~P\\~I&Je'6hlp,\\' __ $163.00 CIl)'h~'f\'I...,-c:n~hor.e ~5l:l~:t\~e'>~\,~(j.":xJ~i\;P~~'olts \ \ < " $375.00. ~C)- ~ ~~ "" ~ ~J!.&)bniY'C . ., ~. $ 50.00 . fop"!. ~O ()I:J 'Q\'Z>" \"\0 ". Super...:s~r LIcense Number '-+ '1 414- ~o~~\v...~ ~:::.~~~'raN S~r.\ic'~ rir F..d~rs Or -{OV . eO"" r~' .c" ' \ \ \<' f!JI:), ~ ,\,"- - " \ D () \ D \ d~j ~\~rnil.g.rioll;,,,,,j[eration or Relocallon vV' ,"~ \ ,~..\ ,;).~oo il;lnps or less Constr. Con"', Numbel _ \ c:'JLo IsLlli- ~ 201 Amps 10400 Amps hpiratiun Date ~ I \ ~ I t>S ~:~~:;~s~~:~o;"~: VO\I~ '''':Bn~bove. .."..._ _Si2narure ofSl,;oervising EI~c!ricjan__ D. ':"'~~ru.r~..c~.:c;~r.c:u.~b j, ':', '", . ~~ , ' ..... . 1. '. 'LOCA'fTO1\' OF TNSTAL1..-l.TW,\':'" ..... 1/4 i' LA.-V\.(L(d . AJfi LEGAL DESCRIPTION /'lSO'Z- ofd.-i. Z 00 2-D I JOB DESCRIPTION VVI ,-+ Co", '^t:'c- -h '" "'- 'r:' <:;;\:~~~:<~~.~~.~ . ':':~ Expiratio:1. Date $ 50.00 $ 69.00 $100.00 . i~ -. l'\cw Alteration or Euen5ion rer rand Ollt: Circuit S 43.00 Each I\dditionul Circuil or with _Qt: Service or Feeder Perr.;,it .,'.)) ~~ E, ~:1isc,.llap';~~; r'iier~ifCi;~'d~'r ~Q.t~~~ach Ins~U~t1~n . . ... . . r:.v~'X:-~ <<,~'" . - Pum? or tmptlOn ~~ q,'X; &4) $ 50 00 S,gn;Oulline LIghl:llg ,,<<; ,\~Co .,<;:S S 50 00 Limited Energl'.'Resil!;.*,~IiS' \~~ , $ 25.00 Luniled En~tWIC~m~~1 {.> ~' $ 45.00 MlnlmulO ~~,:!'J;;~<YIls.:e~ifJl'~ee is $45.00 + Sureh.r~e. . ~ ":>.<:0.\0..<<;: .~CJ~~ '<. ' 4. St'1Jt~'1';g,~~~ ., 50 .. '~. ~",. 'b~ . 7% State su~~... '" ;. -;;-0. 10% ^dmin:sl:~ve Fe.: ~a 5B~ TOTAL OwnrrsName l1i~_ "(::..;-(~c- ~a.eL- AJ Phone 7'17 - 963b 1fL{! ~?rL_ Addres" Cil)' OWNER L-;STALLATIO;o.; The installation is being m(lde or. proper:y l own whicr. is not intcnded for sale, 1co.:s~ or rcnt. Owners Sign.:llure: Ins.pection Requ~t: 726.J769 Sha.."l:d Dri....({T:~'Duildint Fonn.vElcctri:lll PI:r.Uil.\pplie:lion l-OJ.doc