HomeMy WebLinkAboutPermit Building 1997-05-09SPFINGF!ELO
RESIDENTIAI. PERMIT APPI.ICATION
CITY OF SPRINGFIELD
CO}TMI'NITY SERVICES DTVISION
BUII,DING SAFETY
Page 1
ilob Number: 970310
225 North Fifth Street
Springfield, OR 97477
Location of Proposed Work: 2429 34TH ST
Assessors l"tap #z l7O2L93l
Lot: 15 Block: 2
Office:
Inspection Line:
"726 -37 59
726 -37 69
Tax Lot #:
Subdivision:
01115
MONTEBELLO
Owner: SAI{DY I{ARX
Address: 2425 34TH ST
Describe Work: S.F. RESIDENCE
Phone #: 726-L070
city/sEat.e/zip: SPRTNGFTELD, OR 97478
NEW
General:
Plumbing:
Mechanical:
Electrical:
Contractor
MINIUM
DON LEWTS
HARVEY & PRICE OOOOOTT
PO Box 1910 Eugene OR 974400000
AI{TONE
Consts.
Contractor #Expires Phone
L0/3L/9s 746-L621-
QUAD AREA: 5RNC
# OF UNITS: 1
CONSTR. TYPE: VN
SECONDARY HEAT: HP
-- OFFICE USE --
LAND USE: 1111
ZONING CODE: LDR
# OF BDRMS: 3
WATER HEATER: E
# OF BLDGS: 1
OCCY GROUP: R3
HEAT SOURCE: FE
To requeet an inspection, call- the 24 hour recording aL 725-3769.
A11 inspections reguested before 7:00 a.m. will be made t,he same working day,
inspections requested afEer 7:00 a.m. will be made the fol-lowing work day.
--- REQUTRED TNSPECTTONS ---
FOOTING - After t.renches are excavated.
FOITNDATION - After forms are erected but pri-or Eo concrete placement,.
POST AIID BEAI'I - Prior Lo f loor insulation or decking.
IIIDERFLOOR IIECIIAIiIICAL - Prior to insulation or decking.
IIIIDERFLOOR PLUIIBING - Prior to insulation or decking.
LINE TO SEPTIC TAI'IK - Prior to filling trench.
WATER LINE - Prior to filling tsrench.
STORM SEWER LINE - Prior to fil1ing trench.
INSULATION - Floor,' prior to decking Wall/Ceiling; Prior to cover
ROOGH PLT,MBING - Prior Eo cover.
ROUGH MECIIAIIICAL - Prior to cover.
ROUGH ELECTRICAL - Prior To cover.
EIJECTRICAL SERVfCE - Must be approved to obtain permanent power.
FRAMING - Prior to cover.
INSITLATION - Fl-oor; prior to decking wa11/Ceiling; Prior uo cover
DRYWAIJIJ - Prior to taping.
FINAL PLITMBING - When all plumbing work is complete.
FINAL IIECIIAIIICAL - When alI mechanical work is complete.
FINAL ELECTRICAL - When all- electrical work is complete.
FINAL BUIITDING - When aII reguired inspections have been approved and
the building is complete.
House 15
INTERIORLot Faces: N Lot Type:
SetbacksswE
225
N
5
SPH!NGF!ELD
Job Number: 970310
a SPruNGFIELD,
Page 2
It,em
Main
Garage
ToLal Va1ue
Building PermiL Fee
Surcharge/admin
TOTAI, FEE
--- BUII.DING PERMIT ---
Square Feet x
L547
$/Square Feet
64.66
(A)
Value
100, 029 . 00
0.00
100,029.00
435.25
34.82
47 0 .07
--- SYSTEMS DEVETOPMENT CIIARGE (SDC)
(B)793.35
SysEems DevelopmenE Charge is due on all undeveloped properties within the City
limits and the Citys Urban Growth Boundry which are being improved.
--- PLUIIBING PERMIT ---
Item
Residential Bath(s)
Plumbing Permit
Surcharge/aamin
TOTAL CHARGE
3
Fee
L92 .50
L92 .50
L5 .4L
207.9L(c)
--- MECTIAIiIICAL PERMIT ---
Furnace
Exhaust Hood
Vent Fan
Wood Stove / tnsert /Fireplace Unit
Dryer Vent
Mechanical Permit
fssuance
Surcharge/aamin
TOTAI. PERMIT
6.00
4.50
L2 .00
15.00
3.00
(D)
40.50
10.00
3.2s
53 .75
--- I{ISCEI.I.ATiIEOUS PERMITS ---
Surcharge/Admin
WILLAMALANE S/D/C'S
PLAN CHECK FEE
TOTAL ITTISCELLAI{EOUS PERMITS
0.00
1, 000 . 00
282 .91
(E)L,282.9L
(Excluding Electrical)
unlegs otherwiee notsed
--- TOTAI. AMOI'NT DUE ---
(A, B, C, D, and E combined)2, 808.00
--- BUILDTNG VAIJUE, PLAtiI CHECK AIiID BUILDING PERMIT ---
This permit is granted on the express condition that the said construction
sha}1, in all respect,s, conform to the Ordinance adopt,ed by the City of
Springfield, including the Devel-opment 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.
4
SPHINGFIELD
Job Number: 970310
a SPilNGFTEI.D,
Page 3
Received By:
P]ans Reviewed By: BOB BARNIART Date : 05 / 07 / 97
Building Site Reviewed By: HEIDI KNIGHT
.-- ADDTTIONAL COMMEMTS ---
ANNEXATION AGREEMENT REQU]RED
REQUIRES SEPERATE ELECTRICAL PERMIT, PATH 1, HOLD FOR ANNEXATION AGREEMENT,
NEED PERMITS AI{D PAPER WORK FOR SEPTIC SYSTEM
DRIVEWAY REQUIRED TO BE PAVED
By eignature, I state and agree, that I have carefully examined
the completed applicat,ion and do hereby certify that all information hereon
is true and correct, and I furt,her 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 St,at.e of Oregon pert,aining to the work described 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 wit,h oRs 701.055 will be
used on Ehis project.
I further agree Lo ensure Lhat al-l- required inspections are requested at the
proper time, Lhat each address is readable from the street, that the permit
card is located at t,he fronL of the property, and the approved set. of plans
wilI on the site at L Eimes during construction.
s -f- rZ
s Date
VALTDATION
4,5 l(qReceipt Number:
Date Paid:
Amount Received:
Recei-ved By
o
Permit #qrm\)
Address
Issued by:Date: b q q1
Statement: lnformation Notice to Property Owners
About Gonstruction Responsi bilities
Note: Oregon Law, ORS 701.055(1), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement 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 appropriate blanks and initial boxes 1 and2, and either box 3,A. or 38
1. I own, reside in, or will reside in the completed structure
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
34. My general contractor is A kL-8'A
Q',lame)regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
38. I will be my own general contractor
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certiff that information is and that I have read and do understand the Information
about Con Responsibilities on the reyerse side of this form.
94 1)
(Signature of permit
(Thite copy to issuing ogency permit file,
pink copy to applicant)
Notice to Property
(Date)
#Yh,4ffiffi reffiSp#ruS$ffiXL*Y$H$ Ardm ARffi&S $F *SF*{StrRN:
+:*r,],,,ri*.
It*T
'a
ri r':. , r'j , .i'... ,, r-r,t i ':iiirr::
.;:: i r.lilr:- il"lJ']- lli.tl ii
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j*,i,,.].rliii;;jl.t'ir*.lj'...."
.,., ..,' 111 i. ..''.:l
SPFINGFIELD
a
CITY OF SPRINGFIEI.D SYSTE}TS DEVELOPMENT CIIARGE
(RESTDEIIIrAL)
Page 1
Name or Company: SANDY MARX
Location z 2429 34TH ST
Developement T)pe: R Building Size:
,Job No. : 970310
Lot Size Sq Ft
1. STORM DRAINAGE
Impervious Sq Ft 1388
2. SAI{ITARY SEWER - CITY
Number Of PFUs
(see Page 2)
3. TRANSPORTATION
Number Of Units
1X
x Trip Rate
1.010 x
Transportation Totaf
4. SATIIITARY SEWER - M}MC
Number Of PFUs
0
MWMC CREDIT If Applicable (see Page 2)
TOTAI, - MWMC SDC
SITBTOTAL - (Add Items 1, 2, 3 & 4)
X O.2aG Per Sq Ft. =
X 44.75 Per PFU =
Cost Per Trip
45L.25
0
$4ss.77
$299 .81-
$o. oo
$4ss.77
$o. oo
$0.00
$o. oo
$7ss. s8
$37.78
x Per PFU + MWMC Admin Fee
20.690
5. ADMINISTRATIVE FEES
Base Charge (Subtota} Above)x 0.50
TOTAT SDC
Reviewed By: DENNTS ERNST Date: 05/0L/97
$793.35
SPF!NGFIELD
Job Number: 970310
a
FIXTI'RE I'NIT CALCULATION TABLE
Page 2
SPruNGFIELD,
Fixture Tlpe
Number of
New Fixture
Unit
Equivalent
Fixture
Units
Bathtub
Drinking Fountain
Floor Drain
Interceptors For Grease/Oi1/Solids/Etc
Inteceptors For Sand/Auto Wash/Etc
Laundry Tub/Clotheswasher
Clotheswasher - 3 Or More
Receptor For Refrigerator/Water Station/ftc
Receptor for Commercial Sink/Dishwasher/Etc
Shower, Single Stall
Shower, Gang
Sink, Bar, Commercial, Residential Kitchen
UrinaL, Stall/Waf1
Wash Basin/Lavatory, Single
Water Closet, Public Installation
Water Closet, Private
Miscellaneous
TOTA], FIXTURE UNTTS 25
CREDIT CALCULATION TABLE: Based on assessed value. If improvements occured
after annexation date, credits are calcul-ated separately
(caLcul-ations are by $l-000)
Year Annexed:
Credit For Parcel Or Land OnIy If Applicable: 0 X 0.00 = 0.00
Improvement (if after annexation date): 0 X 0.00 = 0.00
CREDIT TOTAL = $0.00
(If Land value is multiplied by 1 then the parcel/land credit is not accurate.)
z
1
a
3
6
6
L
3
a
a
2
t-
6
4
2
0
0
1
0
0
0
1
0
1
U
3
0
3
0
4
0
0
0
0
2
0
0
0,
0
z
0
3
0
L2
0
/,-\SPR'}lGFIELCt
Cig'of Springfield / Developmen. -etrices
Building Safe(v
225 Fifth Street
Job Number
Job Address : t? q 3Yf,l^ atr
Date
To
q - / 5 -0
$L
L
Call for reinsPection Inspector
************************ call for inspection 726_3769 ***r.* Qu 726_37 59* * * * * * * * * * * * * * * * * * *****
)
v<
corpor
day of
to the
NOTICE IS GIVEN THAT
hereinafter referred
*-NOTICE OF
to as
0REGON, County of
Iy appeared before
AIIIIIIEXATTOIII AGREEI{ETVT
r tyo pr mun
hereinafter referred to as the Ci ty,
entered into an agreement governing
ified as Tax Lot //1L , Asses sor's Map
, a legal descriPtion5f-vElchls attached as Exhibit A
rpora re erence,herein.
In UITNESS , the Ovner has set their hand and seal this 77Y daY of
L99
The use and development of the above property is governed by.the terms and conditions
of the Consent to Ann"*.tion document signed- by the Ovner and the City' The Consent
io er,r,"*.tion document is filed in the DEvelopment Services Division of the City, to
vhich reference i;-h;;"bt made for all matterl and things therein contained. This
"gr""-""t is binding on the owner's heirs, assigns and iuccessors in interest to the
Proper tY
As used herein, the singular shall include the p1ural and the plural sha11 include
the singular.
at ion the tate o
proper
e.
Z
?a,rlr^>h Vha*r/
STATE 0F OREGON, CountY of Lan
Personally appeared before me
vithin named
acknovledged
In VITNESS IJHEREOF,the Director
7rl daY of
By
pmen ces rec
r 3
ress
flday of , L997 , the
vho
rvo tary ac
c or
ssion Expires:,/et
has set their hand and seal this
By:
s
STATE OF
Personalvithin named
t2.
By:
7Z
sse)
this
tto
My
or Designee, L99t
o
) ss.
me this 7 4( daY of mAy ,L997, the
wIro
o e r untary ac eed
/r-u;Ahre
My Ct'mmission Expires: /ol7t /??
This Notice of Agreement shal1 be recorded by the 0vner in the Deeds and Records
Department at the Lane County Courthouse. The original of this.Document sha1l bereturned to the _Developqelt Services Department, City of Springfield, 225 Fifthstreet, springfield, oR 97477. The recordation of this Document sfiall be consideredNotice of Agreement.
2gog NoTrcE oF ANNEXATTON AGREEMENT
@
OFFICIALSEAL
JULIA L SCOTT
r.roiMY PUBLIC. OREGON
cdMtittSStOH NO' 048s8s
uI cot{itlsslox txPlf,ts ocl.3l. lssg
@ 048585
lcgg3t,0cT,IxPtRgsc0MMlstl0llMY
LEGAL DESCRIPTION OF PROPERTY
Lot 16, Block 2, FIRST ADDITION TO MONTEBELLO ACRES,
as platted and recorded in Book 34, Page 21, in Lane
County Oregon Plat Records, in Lane County, Oregon.
ATTACHMENT A
SAIVBR OP TT}{E LIHTT ON CONSEI{T TO AIINEXATION
A!{ ADDENDT'I{ TO TEE CONSEI{T TO AI{NEXATION DOCTII{ENT
en
19 entered into an agreement
er dentified as Tax Lot
, a legal description of
re erence,here,in_. and is attachedhereto; and
IIHEREAS, for the purpose of authorizing an annexation under ORS 222.170 orunder a proceeding initiated by ORS 199.490, only statements of Consent to Annexationvhich are filed vithin any one year period shall be effective, unless a separatevritten llaiver of Time Limit document forgoing the one-year period or prestribing
some other period of time has been entered into betveen an ovner of land and theCity; and
VHEREAS, the 0vner, by signing this l,Iaiver of Time Limit, vill comply viththe terms of the Consent to Annexation document so that the Consent to Annexltion
document vill be effective vithout regard to the one year limitation under OregonIav.
NOIJ THEREFORE' in consideration for the City's agreement that the Ovner,sProperty may receive municipal services from the City and the 0vner may undertakedevelopmelt of the-Property in accordance vith the SDC and other appliiable Cityplans''polieies and standards and vith the requirements of Lane County, the 0vnerhereby agrees to vaive the one year period, pursuant to ORS 222.L73. -This l{aiver ofTime Limit is binding upon the Owner, the O.rrner,s heirs, assigns and successors ininterest to the Property possessed by the 0vner.
tto
e7!,
tyi
7k
A^,h^Vr)
Annexation document to the
In the Ovne set their hand and seal this
9
e.By:
ress
STATE 0F OREG0N, County of Lane ) ss.Personally appeared before me this ?rH daY of mAvvithin named
ackno5rledged t tto e rvo ary act
r has
eJ/-day of
, 1997, the
vho -
eed.
By:
77 ress
My
o
ission Expires:to/er, '
r
This a ver of Time Limit shalI be recorded by the 0vner in the Deeds and RecordsDepartment at the Lane County Courthouse. The original of this Document shall bereturned to the _Development Services Department, City of Springfield, 225 FifthStreet, Springfield, OR 97477.
I.IAIVER OF TIME LIMIT
2908
@ ru"fii"f'st6itr-
-*ilffii$;,ffl[d,r"':'m
the Ovner ted aCity on t
sa
, TJHER AS,
nel day of
an annexa t ion to
Assessor's Map
as Exhibi tA
!
l_-
LEGAL DESCRIPTION OF PROPERTY
Lot 16, Block 2, FIRST ADDITION TO MOMEBELLO ACRES,
as platted and recorded ln Book 34, Page 2L, ln Lane
County Oregon Plat Records, in Lane County, Oregon.
ATTACHUENT A
na ter re er to as r
RECITALS: The Ovner represents the foltoving:
1' The Ovner possesses-.gal property, hereinafter referred to as property, moreparticularly described in Exhibit rrArr, attached hereto and nade .'p".i'hereof,located outside City limits, but vithin the adopted Urban Grovth Bbundarydepicted in the Eugene-Springfield Metropolitan Area General p1an.
To: The. City of Springfield, a munihereinafter referred to as City.
This is a Consent to Annexation by
The Ovner consents, pursuant to ORS LZZ.LLI, that theirs, successors and assigns vith an interest in tthis Document vhich shal1 iun vith the property.
CONSEIIT TO AI{NEXATION
FOR T'P-10 T'RBAN FRTNGE OVERI,.AY DISTRICT PROPERTIES
cipal corporation of the State of Oregon,
J?'L- a/,A
The uF-10 urban Fringe overray District described in Artspringfield Development code, hereinafter referred to asProper ty.SDC, has beer applied to
icle 29 of the)
3' By the terms of SDC, Section.29.A7O(1)(a), this Consent to Annexation,hereinafter referred to as this Documentr'is reqrired as a precondition to allovof the land use activity or development desired'by the o*r,"r.
AGREEMENT: The Ovner consents as follovs:
1. The Ovner irrevocably consents to annexation of the property to the City inconsideration for the allovance by the City of a land u!"-"Lti"ity ordevelopment. \
2' The Ovner consents that the city_council, in its sole discretion, nov or at anytime hereafter, may adopt a resLlution initiating .rrn"*.iion under oRS oRSL99'490 and 222.170.or any other applicable Iav 6r "t"tui". The ovner consentsto.including in such proceeding any other land the ciiy-iouncil may Jir;ai-;;'"vhich the Ovner has petitioned and consented to the anirex.iion.
3' The owner understands and consents that this P99rTg!t may be used by the city tomeet the requirements of ORS 199.490 and oRs 222.170.
4' The 0wner also irrevocably authorizes the city to present this Document to theI4tne county Loca1 Government Boundary commission ti initiate any minor boundarychange under ORS 199.490(1) as an interim measure to provide service to theProperty prior to annexation to the City.
5 he Ovner and any and allhe Property shal1 be bound by
CONSENT TO ANNEXATTON _ 1
6' The ovner shall obtain the city's approval for any nev rand use activity ordevelopment, change of land usl activity or development, or intensification ofland use activity or development of the Properly.. The city vilt grant approvalof the land use activity or developme"i ii-il i" il compliance vith appricablepJ-ani, policies, and sta,airas ;;-I;i;;pri."a by the city.
7 ' rn consideration for this Document, -thg city agrees that the property may receivemunicipar services from the city and ah"-o;.r-may undertake the development ofthe Propertv in accordance vith'ciit ;i;ri,'pori"i"" .na-sfanaaras and vith theapplicable requirements of Lane County.
B' As used herein, the singular shaIl include the plural and the prurar sharlinclude the singular.
contemporaneously vith the execution of this consent to Annexation, the ovner isexecuting a separate uaiver of Time Limitation-iorr, p;.;;;;-io ons 222.173,attached hereto and made part of, as a condition of'"ignins iti" oo"ument.
In UI
By:
ress
STATE O
Personavithin named
IIHEREOF, thc
(1.
Ovne
,lg
rhae7.s set their hand and seal this 7*" ?ay of
Zrrr,Au--bn )nBy:
e<
of Lane ) ss.ore me this ?rt day of
to
ress
r untary ac
r
acknovl d e
In I{ITNESS I.IHEREOF,
'7n/day of
By:
q7 ?
F OREGON, CountyI1y appeared bef,, 1.997 ,vho -
the
t
My LSSl on Expires2 /o/34/??
the Director or Designee has set their hand and seal this, 1997.
rec oces
STATE 0F 0REG0N, Coun ty of )ssPersonally appeared before me this tft day of zbvvi thin named
acknovledged t o ng s rumen o rvo act
, lggT ,vho -eed.
the
ta or
My ission Expiresi /o,/),7
@
OFFICIAL SEAL
JULIA L SCOTT
NOTAHY PUBLIC - OREGON
COlvlMlSSlON NO. 048585
MY C0ftlMll$|0[ tXllf,El 0tt, ll' llll
@
OFFICIAL SEAL
JULIA L SCOTT
NOTARY PUBLIC . OREGON
coMMlsstoN No.04858s
MY C0lilMlg$|0[ tXPlf,ti 00T, ll, l0gs
2907
CONSENT TO ANNEXATION - 2
,trl*r
LEGAL DESCRIPTION OT PROPERTY
Lot 16, Block 2, FIRST ADDITION TO I'IONIEBELLO ACRES'
as platted and recorded ln Book 34, Page 2L, in Lane
County Oregon Plat Records, Ln Lane County, Oregon.
ATTACHMENT A
Willamalane
Fa7r. a-n-ecreation District Job. No.
SYSTEM DEVELOPMENT CHARGE
WORKSHEET
NAME:PHONE:
ADDRESS:w srArE: ar zrp: 4140{
LOCATION OF PROPOSED BUILDING SITE:
Street Address:w
Plat Name:fl 01,lq bt Tax Lot Number:
1. DEVELOPMENT TYPE (Check appropriate dwelling(s). SDC calculations and dwelling t
ype definitions are on the back.)
A. Single-FamilY Detached
I Single Family home Manufactured home not in a park
NO. OF UNITS X $1,000 Per unit = $
B. Single-Family Attached
NO. OF UNITS X $924 per unit = $
C. Multi-Family Apartment
NO. OF UNITS X $692 per unit = $
D. Manufactured Home Park
NO. OF UNTTS X $699 Per unit = $
WTLLAMALANE SDC $
2. SDC CREDIT (if applicable) SDc-payer must furnish proof of
Willamalane ireOit'approval. See SoC Crem Worksheet' $
Iooo,-
3. TOTAL WILLAMALANE NET SDC ASS
(if SDC reduced for Credit)
lopme
ESSED
$
q
_hr-r
City of SPring
s Department
5
d,
Date'
4to 0
Zoning
orizecj Signature
#i:1)
Sr; _ TGFIELC,
ELECTRICAL PERHIT
Ci ty Job Number
A?PLICATIONq1 03\c
L225 FIFTH STREET
SPRTNGFTEI^D, oREGoN 97477
fNSPECTI0N REQUEST: 726 .37
0FPICE: 726-3159
1 OFI
ON
ION
Permi ts re non ans fe rabl e and expire
if vork is not ted vi thin 180 days
of issuance or if vork is suspended for
1B0 days.
2. CONTRACTOR INST ON ONLY
Electrical Contrac o
Address
Ci ty Ph e
Supervisor Li e Number
SCMDUI-E BELOV
Nev Residential-Single or
Multi-Fami.ly per dvelling unit.
Service Incl-uded:
I tems\\\
A
B
c
E
Cos t
s 8s.00
s 1s.00
$ 40.00
s s0.00
$ 50.00
s100.00
s 130. 00
s300.00
$ 40.00
Sum
aEove
Expiration Date
Constr Contr. N
Expiration Date
Signat
umber
of-supervising Elect ]an
Temporary Services or Feeders
Installation, Alteration or Relocation
200 amps''or less
201 amps to 400 amps
over 401 to 600 amps
-0ver 600 amps or 1000-7ofTs
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereo f
Each Manuf'd Home or
Modular Dvelling
Service or Feeder
Services or Feeders
Installation, Alterations
or Relocation:
200 amps or less
201 amps to 400 amps
401 amps to 600 amps
-601 amps to 1000 amps_
Over 1000 amps/vo1ts
Reconnect Only
One Circui t
Each Addi tional
Circuit or vith Service
or Feeder Permit
Miscellaneous ( Service/feeder
-Each instal]ation
Pump or irrigation S
Sign/Outline Lighting- S
Limited Energy/Res
-
$
Limited Energy/Comm $
SUBTOTAL OF ABOVE
5Z State Surcharge
32 Administrative Fee
TorAL
l-
_L
81
l9
Ovne
Addr
Ci ty
Name
D. Branch Circui. ts
Nev, Alteration or Extension Per Panel
$ 40.00
$ ss.00
s 80.00
see ttBtt
00
00
00
00
ess
O\INER ALLATIO
Phone
N
The installation is being made on
property f ovn vhich is not intended
for sale, lease or rent.
Ovners Signature:
DATE:
121-0315F
s 3s.00
$ 2.00
included )
5
t
r)rrnr:-t-I/rln Il v
not
40.
40.
20.
36.
I