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HomeMy WebLinkAboutPermit Building 1992-03-16SPrrI^rGFIELO RESIDENTIAL PERMTT APPLICATION lnspcctions: 726-3769 Officc: 726.3759 LOCNTION OF PROPOSED WORK ASSESSORS MAP: - -70e 3 OWNER ADDRESS: CITY: CONTRACTOTT'S NAMt: CENERAL: PLTJMAINC: MtTCHANICAL ELECTRICAL: Sile lnspection - To be made af ter excavation, but prior to setting forms. Underslab Plumbing / Electrical / Mechanical - Prior to cover. JoB NUMBE ^9-ru39*, efr, 225'Fif th Street Springfielcl, oregorr gi q77 ,SrtI 15"+ l'q Lor: l-BLOCK IAX LOT: SUBDIVISION PHONE €r-+ e_-srArE: eWq -4tK;l::ZIP Fc, D-8. : _ ADDRESS tg6-tD;\lnw,fie- CONST. CONTRACTOR 't EXPIRES PI-ION E Q3-s77 r'l'. To request an inspection, you must call 726-3769. This ls a24hour recording. All inspections requested before 7:00 a.m. will be macle the same working day, inspections requested after 7:00 a.m. will be rnade the following work day. REOUIRED INSPECTIONS w w f-V Final Electrical - When allL41 electrical work is cornplete. fVl Temporary Eleclric -,/zvp drzzCzn Rough Mechanical - Prior to fncover. wB Wl orVwatl - Prior to taping Wood Slove - After installation lnserl - After flreplace approval and installatlon of unit. Curbcut & Approach - After forms are erected but prior to placement of concrete. w Rough Electrical - Prior to cover. Electrical Service - Must be approved to obtain permanent' electrical power. Fireplace - Prior to facing materlals and framing lnsp. Framing - Prior to cover. Wall/Ceiling lnsulation - Prior to cover. Final Plumbing - When all plumbing worl( is complete. Final Mechanical - When all mechanical work is complete. Final Building - Wlren all required inspections havc. been approvecl and building is completed. Footing - After trenches are excavaled. Masonry - Steel location, boncl bearrrs, grouting. Foundation - After forrns are erected t)ut prior to concret() placernen t. Underground Plumbing - Prior to filllng trench. Underlloor Plumbing/ Mechanical - Prior to insulation or decking. Post and Beam - Prior to floor insulation or decl<ing. Sanitary Sewer - Prior to filling trench. w w n w a A a fV Floor lnsulation - Prior tolAJ decking.w w W4o,n.,%5refuee CIn{ Sidewalk & Driveway - After excavation is complete, forrns and sub-base material in place. f_l Fence - When cornpletccl Slreet Trees - When all required trecs are planted. t MOBI HOM IN S Blocking and Set-Up - When all blocking is complete. Plumbing Connections - When home has been con.nected to water and sewer. Electrical Connection i- When blocking, set-up, ancl plumbing inspections have been approved and the home is connected to the service panel. Final - After all re<luired inspections are approved and porches, skirting, decks, and venting have been installecl. hqqi€- sPE@roN ffi Storm Sewer - Prior to fillingl'4 trench. IXY"*: Line - Prior lo fillins|+ trcncll. ffi Rough Plumbing - Prior to - covcr. . i.- EN €DESCRIBE WORI(: ADDITION DEMOLISH OTHERNEW / REMODEL a\2 n €,IRANGE: OCCY GROUP: WATER HEATER: g OF STORIES: FI-OOD PLAIN Y OF UNITS: OUAD AREA: # OF ALDGS SECONDARY HEAT: SOUARE FOOTAGE: ZONING COD # OF BDRMS: - oFFtc LAND USE: ll CONSTR. TYPE: HEAT SOURCE: B a E r tl Lot Iaces Lot sq. ftg. Lot coverage TopograPhY Total height Lot Type -. ln terior -Corner --- Panhariile - Cul-de-sac Setbacks P.L, N S c teZo ?& E GARHSE ,blz //d /d' I THE PROPOSED WORK IN THE -lIISTOBICAL DISTRICT, OR ON THE, HISTORICAL REGISTER? - lf ycs, tlris application must be signed and aPProved bY thc Historical CootcJirrator prior to pernrit issuance' APPROVED: ewcd B BUILDING VALUE, PLAN CHECK AND BUILDING PERMIT This pcrnrit is grarrted on tlte express conditiorr tlrat the said consiruction shall, in all respecls, conform to the Ordirrance adoptecl by thc City of Springfield, including the Developrtcnt Code, rellulating the construction and ttse of buildings, and may bc suspen<1ed or revol<ed at any tinlc upon violation of any Provisions o[ said ordinances' PIan check Fee:.-- %3j "- BUILDING PERM!T VALUE %,za_?45_16_ /:22:2? Date(A) /L-7> X $/SO. FT. 3: Receipt Numbe Date Paid Received BY: SO. FT. %a-- ITEM Main G arage Carport Total Value Builcling Permit Fee State Surcharge Total Fee aaa,e9 -ZAH/%.2 Systems Developrnent Charge is due on all undeveloped properties within the City limits which are being improved'sYSr E M s D EV E Lo P * r *r,"l r ^ L%lrr? * ITIONAL COMMENTS ITEM Fixtu res Residential Bath(s) SanitarY Scwcr Watcr Storm Sewer Mobile Home N' zx /? I i7a;2-'2 FEE FT. (c) Z 2? PLUMBING PERMIT rr. FT. Plumbing Permit State Surcharge Total Charge ,, a2_le. v3a-aP MECHANICAL PERMIT Fu rnace Exhaust Hood 2X4r;2 Woo<J Stove/ lnscrt / Fireplace Unit 2*7 Vz.z6:(D) a64Drycr Vctlt Vent Fan N" ?XV Mechat-rical Pcrtrtit lssuance State Surcharge Total Permit - I aA.4t. abJa._/, o, -? aD(D. By signature, I state anc.l agree, that I have caref ully examined the completed application and do hereby certify that all informationhereonistrueandcorrect,andlfurthercertify that any and all worl< ;:erformed shall be done in accordance with ttlc Ordinatrcr:s ol tlrr: City o{ Sprirrgfir:ltl,;rrrd l}rc L;tw:; of tlre Statc oI Orcllotl pr:rtairrin.q to tlle w<:)tk tlr:scril;c<l Ircrein, ;rtrcl lltat NO OCCUPANCY will bt: ttta<lr-' of i.ttty structurc witlrout lrcrtrtissiotr of the Buildinl; Safcty Division' I f urthcr ccrtif y tllat orlly contractors ;rncl otttploycr-'s wtlo are in cornpliancc witll ORS 701 O55 will t-:o r'rsecl on tltis proiect. I f urther agree to cnsurc that all required inspections are requested at the proper time, lhat each address is readable at all tim Signatu re Date from the street, that the P ermit card is located at the front d set pl n remainof the pro uctioon the MISCELLANEOUS PERMITS Mobile Home State lssuance State Surcharge Sidewalk -Q-- n curbcut ff;- ,, Demolition State Surcharge Total Miscellaneous Perrnits (E) /q-o> y'?..% /<'/2--7q1 VALIDATION: RECEIPT NUMBER 7'€ -.q-a 1-7?DATE PAID RECEIVED BY AMOUNT RECEIVED TOTAL AMOUNT DUE (excluding electrical) (A, B, C, D, arrcl E Combined) 9236-9 Yo'z?&' 4P.a> I.a IC'TY OF 225 FIFTB STPGET SPRINGFIELD, ORBGON 97477 INSPECTION RBQIBSTt 726-3769 0FPICE: 726-3759 1. LOCATION OP INSTALI,ATION LBGAL DESCRIPTION JOB DESCRIPTION Permits are non-transferable and expireif vork is not started vithin 180 daysof issuance or if vork is suspended for 180 days. 2. COMRACTOR INSTALI..ATION ONLY Electrical Contractor Address Ci ty Supe sl'rilN(;FTELU 1000 sq.ft. or less Each additional 500 sq. ft or portion thereo f Each Manuf'd Home or Modular Dvelling Service or Feeder B. Services or Feeders Installation, Alterations or ffiR eloca t i on : 200 amps or less 201 amps to 400 amps -401 amps to 600 amps _601 amps to 1000 amps_ 0ver 1000 amps/volts Reconnect 0n1y Aitr ELECTRICAL PERHIT APPLICATION city Job Nu b", ??OVBE COXPI.^ETB PEE SCEEDULE BELOS Nev Residential-Single or MuIti-FamiIy per dwelling unit. Service fncluded:Items Cost ? $ 1s.00 72 s 40.00 3 A Sum s s0.00 $ 60.00 €,1 - phoneT/>--? rvisor License Number ;97 ? "- >; $100.00 $130.00 $300.00 $ 40.00 Expiration Date y'd-az- constr contr. Number 3l l5{<-- c' Expiration Date /A -f Z-' Signature of Electrician 44 rs Name Address 4 OIINER INSTALI..ATION The installation is being made on property I own vhich is not intended for sale, lease or rent. Ovners Signature: DATE: RECETPT Temporary Services or Feeders Installation, Alteration or Relocation 200 amps or less / $ 40.00 201 amps to 4oo amps * S 55.00 Over 40L to 600 amps _ $ 80.00 0ver 600 amps or 1000 volts see I'Bfl a aEoE not included) 40.00 40. oo 20.00 cirv ?q4phoneA*aff57 D. Branch Circuits New, Alteration or Extension Per Pane1 One Circuit $ 35.00 Each Addi tional Circuit or vith Service or Feeder Permit $ 2.00 E Miscellaneous ( Service/feeder -Each installation Pump or irrigation $ Sign/Out1ine Lightine- S t imited Energy/Res - S Limited Energy/Comm _ S SUBTOTAL OP ABOVB 5Z State Surcharge TOTAL RECEIVED BY: 5 2y'2.6€ "a ar6/1-efz-e ,a a :ia't ul.lc;l'ILLL) 0i! 225 ITIITII STRIIIiT st,RINGFrIiLD, OIIEGON INSPECf,ION REQUEST: oFPICE: 726-3159 1 ON 97 471 726-37 €s B C COHPI,BTE FEB SCIEDULE BELOV APPLICATION al-Single or per dvelling uni t. ee ilBil (YUdP,H3T olq3 Service Included: Items Cost 1.000 sq.ft. or less Each additional 500 sq. ft or portion thereo f Each Manuf 'd llome or Modular DweIling Service or Feeder $ 8s.00 $ 15.00 $ 40.00 Services or Feeders Installation, Alterations or Relocation: A200 amps or less d 201 amps to 400 amps _ 401 amps to 600 amps _ 601 amps to 1000 amps_ 0ver 1000 amps/volts Reconnect Only Temporary Services or Feeders Installatlon, Alteration or Relocation iden t i tallation rrigation ine Lighting_ nergy/Res nergy/Comrn _ A HuI t i- Sum PTIONC\- Permits are non-transferable and expire if vork is not started vithin 180 days of issuance or if vork is suspended for 180 days. 2. CONTRACTOR INSTAL ION ONI,Y Electrical Cont ractor Add r Ci ty Supe ess oll rv r sor icense Number s s0.00 $ 60.00 $ 100. 0o $130.00 $300.00 $ 40.00 Expiration Date Constr Contr. Number Expiration Date Signature rv].sl EIec tri cian Ovners Name Add ress Ci ty one OVNER ALLATION The installation is being made on property I own vhich is not intended for sale, Iease or rent. Ovners Signature: DATE: 200 amps or less $ 201 amps to 400 amps _ $ 0ver 401 to 600 amps _ $ 0ver 600 amps or 1000 volts s 40.00 55.00 80.00 above D. Branch Circuits Nev, Alteratlon or Extension Per Panel One Ci rcui t Each Addi t ional Circuit or with Servi or Feeder Permi t $ 3s.00 $ 2.007b eo E. Hiscellaneous (Service/feeder not included) -Each Prrmp o Sign/0 Limi te Limi te insri ut1 dE dE 40. 00 40.00 20.00 36.00 5 STIBTOTAL OP ABOVE 5Z State Surcharge TOTALr0( RIiCEIVID IIY: $ $ s s PERHIT Ci Number @ c &) C'TY OF S OFEGO'U SPlrTllGFIELD 225 FIrTE STREBT SPRTNGFTEIJ, OREGON 97477 (, INSPECTI0N REQUBST: 726-3769 0PPICE: 726-3759 Cu":b Pe its are n t rans f exp lreifvork is not started vithin 180 days of issuance or lf vork ls suspended for 180 days. 2. COITITRACTOR ONLI Electrical Contrac or Address cit Phone Superv License Number Explration Date q Constr Contr. Number Expiration Date Slgna ture of Supervlsing Electrician rs Name Address Cl ty pnon" (/ OSNER The installation is being made on property I own which is not intended for sale, lease or rent. Orners Signature: DATE: EIJCTRICAL PERT{IT APPLICATION City Job Nunber COTIPLETE PEB SCEEDULE BELOV Nev Residential-Sing1e or MuIti-Family per dvelling unit. Service Included:Items Cost 1000 sq.ft. or less Each additional 500 sq. ft or portion thereof Each Hanuf'd Home or -Modular DveIIing Service or Feeder $ 8s.00 s 1s.00 $ 40.00 Services or FeedersInstallation, Alteratlons or Relocation: l^0R '_ l>*-'AG 1 rlff5.frET"bqt3 Sum B c D, Branch Circuits New,Alteration or Extension Per Panel 200 amps or Iess 201 amps to 400 amps -401 amps to 600 amps -601 amps to 1000 amps_ Over 1000 amps/volts Reconnect Only Temporary Services or Feeders Installation, Alteratlon or Relocation - 200 amps or }ess "S 40.00 201 amps to 400 amps - $ 55.00 over 401 to 600 amps - $ 80.00 Over 600 amps or 1000-Til[s see uBu a5tiE s s0.00 $ 60.00 $100.00 $130.00 $300.00 $ 40.00 /a one Circuit .-:"/ S 35.00 Each AdditionalCircuit or vith Service or Feeder Permit $ .2.00 E. Miscellaneous (Service/feeder not included) -Each installation Pump or irrigation sign/0utIine Lighting- t,imi ted Energy/Res -Limi ted Energy/Comm $ 40.00 s 40.00 $ 20.00 $ 36.00 SUBTOTAL OT ABOVB5f State Surcharge TOTAL RECBIVBD 5 t+ l?) ct) ard\h ttttn .(p !! JOs N0.AU2hb- crTy 0F sp--r{cFIELD SysTEHS DEVEL0PMET". c[{ARGE WORKSHEET , (c0t{t{ERcIAL & RESIDENTIAL) NAIIE OR COI1PANY:G*e * V*"tev C-o . oe ot l Ir.fC . LocATIoN: lru4t6, +*r<u Loo, \1orVrz,-lqtz DEVELOPMENT TYPE:Mr:e - n.\ew Dupr 9-L BUILDING SIZE:OT SIZE s a. Fr. 1. STORM DRAINAGE IMpERvIoUs sQ. FT. tRq + x $0.186 PER sQ. FT- S-"1o?9-(i."n.,.rseFornuffiIfActualImperv.AreaIsUnknown) 2. SANITARY SEI.'ER-CITY NO. OF PFU'S ?z X 538.55 PER PFU s lzbbG: (See Reverse To Deternine Total PFU'S) 3. TRANSPORTATION NO OF UNITS X TRIP RATE X COST PER TRIP L x ,o09 x s388-61 s 18tl9- x x $388-51 s x $88-6I s (See. Attachment C To 4 ADI.IiNISTRATIVE FEES 'BASE CHARGE (SUBT0TAL A80VE) X .0s s I tcl &9- TorAL-cITY soc s L9o*9 5. SANITARY SEI.IER.HI.IHC N0. OF PFU,S bL x 513.25 PER PFU .+ S!0 t'|l{t'lc AOI{IN. FEE S 4b4=_ (Use PFU Total From Item 2 Above) Mr.rMc CREDIT IF APPLICAELE (SEE REVERSE)s 4o13 T0TAL-HI,JMC SDC S 7nbL3 K p Burd ck Determine Trip Rates 51'BTOTAT )'(ADD ITEl.lS 1,2, & 3) S2?Z*3'-'- SDC Coordinator 7 a az s2 B r* TOTAL SOC FTXTURE UNIT CALCULATION TABLE: rlumoer ol Nert Firures X Unit Equivalerll = Fixture Units (t'JoTE For rernodels, calculate only the tr!fl Jiiional {ixrures) NUMBEF OF UNIT FIXTURE FIXTURE TYPE NEW FIKTURES EOUIVALENT UNITS L z+ Floor Drain-. lnterceptors For Grease/Oil/Sotids/Etc---------------- I nterceptors For Sand/Auto Wash/Etc---------:.------LLaundry Clotheswasher - 3 Or Mobile Home Park Trap (1 Per Trailer)-------- Receptor For Refrigerator/'\ffater Station/Erc-------- Receptor For Commercial Sink/Dishwasher/Etc-: Shower. Singte Qr2lt L -vT Miscellaneous:. TOTAL FIxruRE UNTTS 2--l / rArr rAar E. Eraaa{ aa a<o<sl rahro I rred after annocation datg in faHe'cBEDtT CALCUI-AION TABI E: Based on assessed value lf lmprorernents occu credits Credit for Parcd or [-and Onty lf Apflicable lmprwement Sf after annocatbo date) L,(-xs r6 .91 4o13 (Rate X Assessed Value) (Rate X Assessed Value) CREDIT TOTAL - S 4o-3 2 1 2 3 6 2 6 6 1 3 2 1 2 2 1 6 4 /HeadShower. Gang-......-.-. Sink Bar. Commercial Wash Basin/Lavatory. Single------ Water CIoset, Public lnstallatioru- Water Closel Private-..-- 7 _ lb t<o xs Year' Anne<ed Bate per S1.00O Assbssed VatueYear Annexiid Rate perS|.0OO AssessedVdue 1S5 1986 1987 1988 1989 1S0 sl.69 1-35 1-15 o-92 o59 o.23 1979 or before 1980 1981 1982 1983 1984 sz66 2& 253 L47 z1g ZM IMPERVIOUS AREA = TOTAL LOT SIZE X RUNOFF COEFFICIENT L 1l llnra RUNOFF COEFFICIENTS FOR STORM DRAINAGE RESIDENTIAL PERMIT APPLICATION lnspections: 726-3769 Office: 726-3759 LOCATION OF PROPOSED WORK: SPRINGFTELE) t-) o:r'4"4I JoBNUMBE" qeO 388-- 225 Fifth Street Springfleld, Oregon 97477 TAX LOT:nlq 11 Zfr, ASSESSORS MAP: LOT:BLOCK:SUBDIVISION PHONE: cfiyi €b/2?1., &ZIP: 2,47-7n)/ STATE:D,Z ADDRESS OWNER REMODEL ADDITION DEMOLISH OTHER DESCRIBE WORK: ruEW ,t( ADDRESS EXPIRES PHONEr+* CONTBACTOR'S NAME MECHANICAL: ELECTRICAL: PLUMBING: GENERAL: CONST. CONTRACTOR # \ SQUARE FOOTAG \\\ RANGE: # OF BDRMS WATER HEATER: - OFFICE USE _ LAND USE: ZONING CODE: FLOOD PLAIN SECONDARY HEAT: * OF UNITS: OCCY GROUP: * OF STORIEST QUAD AREA: r OF BLDGS: C.ONSTR. TYPE: llEAT SOURCE: To request an inspection, you must call 726-3769. Thls ls a 24 hour recording. All lnspections requested before 7:O0 a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following work day. REOUIRED INSPECTIONS Temporary Electrlc Rough Mechanical - Prior to cover. Final Plumbing - When atlplumbing work is complete. Site lnspectlon - To be made after excavation, but prior to setting forms. Rough Electrical - Prior to Final Electrical - When all electrical work is complete.cover. Underslab Plumbing/ Electrical / Mechanical - Prior to cover.Electrical Service - Must be approved to obtaln permanent electrical power. Final Mechanical - When all mechanical work is complete. Footing - After trenches are excavated.Fireplace - Prior to faclng materlals and framlng lnsp. w Final Building - When all required inspections have been approved and building is completed.Masonry - Steel locatlon, bond beams, grouting.Framing - Prior to cover. Foundalion - After forms are erected but prior to concrete placement. Other Wall/Ceiling lnsulation - Prior to cover. tl Underground Plumbing - Prior to filling trench.Drywall - Prior to taping. MOBILE HOME INSPECTIONS Underlloor Plumbing/ Mechanical - Prior to insulation or decking.Wood Stove - After installation Post and Beam - Prior to floor insulation or decking.lnsert - After fireplace approval and installation of unit. Blocking and Set.Up - When all blocking is complete. Floor lnsulatlon - Prior to decking.Curbcut & Approach - After forms are erectec, but prior to placement of concrete. Plumbing Connections - When home has been connected to water and sewer. Sanitary Sewer - Prior to filling trench.Electrical Connection - When blocking, set-up, and plumbing inspections have been approved and the home is connected to the service panel. Slorm Sewer - Prior to filling trench. Sidewalk & Driveway - After excavation is complete, forms and sub-base material in place. Water Line - Prlor to fllling trench.[-_l Fence - When completed Street Trees - When all required trees are planted. Final - After all required inspections are approved and porches, skirting, decks, and venting have been installed. Rough Plumbing - Prior to cover. *(da \ .qa fl E Er E tf Lot faces Lot sq. ftg. Lot coverage Topography Total height Lot Typ,- - lnterior - Corner - Panhandle - Cul-de-sac Setbacks IS THE PBOPOSED WORK IN.THE HISTORICAL DISTRICT, OR ON THE HISTORICAL BEGISTER? - lf yes, this application must be signed and approved by the Historical Coordinator prior to permit issuance. APPROVED P.L.HSE GAR ACC N S /2 -. E VALUE ?5ZXLp 1/f,22.2v (A) X $/SQ. FT. lq tD 1ffi Total Value Bullding Permit Fee State Surcharge Total Fee BUILDING PERMIT ITEM SQ. FT, Main Garage Carport BUILDING VALUE, PLAN CHECK AND BUILDING PERMIT This permit is granted on the express condition that the said construction shall, in all respects, conform to the Ordinance adopted by the City of Springfield, including the Development Code, regulating the construction and use of buildings, and may be suspended or revoked at any time upon violation of any provisions of said ordinances. ewed By Date i)-| -q? Recei pt *u^our, (&.18 By:Qq Plan Check Fee: Date Paid Rec SYSTEMS DEVELOPMENT C (B) HAR?E (sD8 6 Systems Development Charge is due on all undeveloped properties within the City limits which are being improved. ITEM Fixtures Residential Bath(s) Sanitary Sewer Water Storm Sewer Mobile Home FEE (c) No FT. FT. FT. PLUMBING PERMIT Plumbing Permit State Surcharge Total Charge ADDITIONAL COMMENTS Wood Stove/ Insert/ Fireplace Unit Dryer Vent (D) N0Vent Fan Mechanical Permit lssuance State Surcharge Total Permit MECHANICAL PERMIT Fu rnace Exh.aust Hood 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 f urther 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 OCCUPANCy will be made of any structure without permission of the Building Safety Division. I further certify that only contractors and employees who are in compliance with ORS 201.055 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 ls located at the front of the property, and the approved set of plans will remain Signature Date on the site at all time ng construction MISCELLANEOUS PERMITS Mobile Home State lssuance State Surcharge Sidewalk - ft Curbcut - ft Demolition State Surcharge Total Miscellaneous Permits (E) TOTAL AMOUNT DUE (exctuding etectricat) (A, B, C, D, and E Combined) /a 77 IV DATE PAID RECEIVED AMOUNT VALIDATION: RECEIPT NUM - JoB No ' 1zo?b b CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE WORKSHEET (C0MMERCIAL & RESIDENTIAL) NAME OR COMPANY:G<ee*Vutt-z>t Co. oF OR.ECrtN TIC LOCATION ' ,U, ,^,ru ,oo " \1ozz'zzz t ' o ln \7 DEVELOPMENT TYPE:MoK xlew BUILDTN G SIZE : l? tz!SIZ sQ. Ft. I. STORM DRAINAGE IMPERVIOUS SQ. FT.21?x $0.192 PER SQ. FT. 2. SANITARY SEt^,ER_CITY (See Reverse) 3. TRANS TAT I ON NO OF UNITS X TRIP RATE X COST PER TRIP X x $40I.05 x -- x $401.05 x x $401.05 $ $ SUBT0TAL (ADD ITEMS I,2, & 3)$ +z+Z- 4. ADMIN ISTRATIVE FEES BASE CHARGE (SUBT0TAL ABoVE) X .05 TOTAL-CITY SDC sbb 5. SAN ITARY SEt,lER-MI,JMC NO. OF PFU'S $13.62 PER PFU + $IO MI^IMC ADMIN. FEE $ (Use PFU Total From Item 2 Above MWMC CREDIT IF APPLICABLE (SEE REVERSE) TOTAL-MI^,MC SDC TOTAL SDCK'ip Burd'ick SDC Coordinator F ) o 4 nbL IL l/' $ x >z+3