HomeMy WebLinkAboutPermit Building 1993-06-11ST'R!]\lGFtELE)RESIDET\iTIAL
PERMIT APPLICATION
lnspections 726-3709
Of f ice: 726-3759
LOC/"TlOl'l oF PROPOSED WORK: -
h,
JoBNUMBE"@
225 Fifth Street
Springfield, Oregon 97 477
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ASSt SSORIi MAP:
-
/?2 ?
LOT:
TAX LOT:
BLOCK: SUBD|V|SION
PHONE
ZIP:
Lacfiq
STATE:
oOWNER
OtvCITY
ADDRESS:qvL
-lr-,x
(/DEMOLISH OTHER -
DESCRIBE \r'/ORK
IJEW REMODEL ADDITION
ADDRFSS EXPIRES PHONEduACON TRNCT()R'S NN ME
GENERNL
ELECTRICAL
CONST.
CONTRACTOR ,
PLUl\,4BING: -
MECHANIC,CL
. , SECONDARY HEAT:
SQUARE FOOT,AGE
""177 f= -
# OF BDRMS
WATER HENTER:
-
# OF STORIESI
, OF BLDGS: ,.
-
OUAD ARE
ZONING CODE:
FLOOD PLAIN
I OF UNITS:
LAND USE:
oCcY GRouP,- ,S
RANGE:
CONSTR. TYPE:
HEAT SOURCE:
To request;rn inspection, you must call 726-3769. This is a24hour recording. All inspections requested beforeT:00 a.m. will be
madt-'the same working day, inspections requested after 7:00 a.m. will be made the follcwing work day.
REQUIRED INSPECTIONS
Temporary Electric Rough Mechanical - Prior to
cover.
Final Plumbing - When all
plumbing worl< is complete.
E
r
B
Site lnspection - To be macJe
af tcr ,:x<;avation, but prior to
settir g {orms.,X Rough Electrical - Prior to IV1 final Electrical - When all
,,lA\etectrical work is complere.c cr/e r.
Underslab Plumbing/ Electrical /
Mechanical - Prior to cover.Electrical Service - lrlust be
:rpproved to obtain permanent
electrical power.
[]Final Mechanical - When all
mechanical work is complete.
Footing - After trenches are
excavaled.Fireplace - Prior to facing
materlals and framing lnsp.
f51r[ finat Building - When all)Agequired inspections have been
approved and building is
completed.Masonry - Steel location, bond
beams, grouting.
f,"^*'ng - Prior to cover'
w OtherFoundation - After forms are
erected but prior to concrete
placernent.Wall/Ceiling lnsulalion - Prior to
cover.
Underground Plumbing - Prtor
to fill ng trench.Drywall - Prior to taping
MOBILE HOME INSPE TIONS
Underlloor Plumbing / Mechanical
- Pr,or to insulation or decking.Wood Stove - After installation
fl Post and Beam - Pricr to fl()or
insul;rtion or decking.lnsert - After iirsp:;.ce approval
and rnstallation cf unit.
Blocking and Set-Up - When all
blccki ng is complete.
Floor lnsulation - Prior to
decki ng.Curbcut & Approach - After
forms are erected but Ptior to
placement of concrr:le.
Plumbing Connections - When
home has been connected to
water and sewer.
Sanitary Sewer - Prior to f iliing
trenc'r.Eleclrical Connection - When
blocking, set-uP, and Plumbing
inspections have been aPProvcd
and ltre hotnc is connectcd to
the service panel.
[-- | Srornr Scwet - Pt;'11 1e f iliir !L' trr-.nc t.
i -i Water Line - Prror to fillingL_l rrcfrc..r.
Sidewalk & DrivewaY - Aiter
cxcavalton is comPletc, forms
anrJ sutr-base nlaterial i': piace.
Fence - When coniPleted.
Rough Plumbing - Prior to
Final - After all requirecl
rnspections are approved and
porches, skirting, decks, and
venting have been installed.n cover
i---l S:reel Trees - lVhurt a:l requtted| | tr"". are planled.
.4//9
fl
E
E
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LJ
I
rup
t
L]
Lot faces
Lot sq. ftg.
Lot coverage
TopograPhY
Total height
Lot Type
-
lnterior
-
Corner
-
Panhandle
-
Cul'de-sacN
ks
P.L.HSE GAR ACC
N
S
E
IS THE PROPOSED WORK IN THE
HISTORICAL DISTRICT, OR ON
THE HISTOFIICAL BEGISTEFI?
--lf yes, this application must be signed
and aPProved bY the tJistorical
Coordinator prior to permit lssuance'
APPRO\,/ED
BUILDING VALUE, PLAN CHECK
AND BUII.DING PERMIT
This perrnit is grantcd on the express conclition ttrat the said
consiruction shall, in all respects, conform to the Ordinance
oOop,uO by the City of Springfield' incltrdrng the
Development Code, regtrlating the construction and use of
buildings, and may be suspended or revoked at any trme
upon vtlation of any provisions of said ordinarrces'
Dare Paic: -*e€> -
43kt
ewed
%
Receipt N umber:-
Received BY
Plan Clreck Fee:
BUILDING PERMIT
VALUE
/4to
(A)
SQ. FT. X $/SQ. FT.ITEM
Main
Garage
Carport
eb,
Total Value
Building Permit Fee
State Surcharge
Total Fee
Systems Development Charge is due on all undeveloped
properties within the City limits which are being improved'SYSTEMS DEVELOPMENT CHARG ,
(B)0
(SD
ADDITTONAL COMMENTS
ITEM
Fixtures
Residential Bath(s)
SanitarY Sewer
Water
Storm Sewer
Mobile Home
FEE
(c)
N0
FT.
FT.
FT.
PLUMBING PERMIT
Plumbing Permit
State Surcharge
Total Charge
Wood Stove/ lnsert/ Fi replace Unit
Dryer Vent
MECHANICAL PERMIT
(D)
N0
Mechanical Permit
lssuance
State Surcharge
Total Permit
Fu rn ace
Exhaust Hood
Vent Fan
By signature, I state and agree, that I have care{ully examined
the completed application and do hereby certify that all
information hereon is true and correct, and I f urther certif y
that any and all work performed shall be done in accordance
with the Ordinances of the City of Springf ield, and the Laws
of the State of Oregon pertaining to the work described
herein, and that NO OCCUPANCY will be marde of any
structure without permission of the Building Safety Division'
I further certify that only contractors and employees t'vho
are in compliance with ORS 701.055 will be used on this
project.
I further agree to ensure that all requircd inspcction;; are
requested at the proper time, that each address rs readable
from the street, that the permit card is located at the front
of the property, and the approvecl set of plans will renrain
nat u re
Date
2
ngon the site at all times struct
MISCELLANEOUS PERMITS
Mobile Home
State lssuance
state surcharge
Sidewalk .-.ft
Curbcut
-
ft
Demolition
State Surcharge
Total Miscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, D and E Comblned)
G,
VALIDAJION
FECEIPT NUMBER
DATE PAID
Ai\,,iOUNT AECE
RECEIVED BY \
*
)
Fill in
Permit No
Address:
lssued Date
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.
licable blanks, and initial boxes 1 and 2, and either box 3A or 38
I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
1
2
3 A
Contractor registration number-.
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
3.8 I will be my own general contractor.
lf I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. lf 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 lnlormation Notice to Property Owners about Construction Responsibilities on the
reverse side ol this form.
6-z/- %
na ure o rm Date
CONSTRUCTION CONTRACTORS BOARD
0244J Bt91
My general contractor is ,
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
lf you are acting aS your own contractor to construct a new home or make a substantial impf&ement to an
existing structure, you can prevent r.nany problems by.being aware of the following responsibilkias and areas
of concern
EMPLOYER RESPONSIBILIT'ES. '
lf you hire persons not registered with the Construction Contractors Boar( to do labor in constructing or assisting
in the construction or imprduement of a residential structu're, you witl, in most instances, be Yuled 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 an employer, you must withhold income taxes from employee wages at
uwillbeliableforthetaxpaymentsevenifyoudon,tactuallywithholdthe
tax from your employees. For more information, call the Oregon Departrnen! o$Revenue at 378-3390.
Unemployment lnsurance Tax
, . '.:. " , :
As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For rnore information, cal.l the Oregon Employment Division DHR
at 378-3224.
Workers' Compensation lnsurance: As an employer, you are subject to the Oregon Workers'Compensation
Law, and must obtain workers' compensation insurance for your employees. lf you fail to obtain workers'
compensation insurance, you may be subject to penalties and'will be liable for all cldim cosfis ifbne of your
employees is injured on the job. For more information, callthe Workers' Compensation Division DIF at 973-7434.
U.S. lnternal Revenue Service: As an employer, you must withhold tgderal income tax from employees'wages.
yment.evenitvouoion'tactuallywit.iitrolothetax.Formoreinfoimation,call
the lnternal Revenue.service at 2Zt-SgOb. -'ri :
OTHER RESPONSIBILITIES AND AREAS OF CONCERN
Code.ComSiance: As the permit holder for this project,you are responsible for resolving any failure to meet
code requirements that may be brought to your attention through inspections,
Liability and Property Damage lnsuranee: 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 your 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.
lf you have additional questions, write to:Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-3/8-4621
NOTE: This lnformation Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
passed by the 1989 Oregon Legislature.
0244J 10124189
JoB N0 . Qbol34
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE
WORKSHEET
(CoMMERCIAL & RESIDENTIAL)
NAME OR COMPANY:
LOCAT IoN: 29+N.38u ft.lToz>t4z- ooil?
DEVELOPMENT TYPE: LDR_ APOITION
BUILDING SIZE: 204?b tNLLoDes AvqOT SIZ S a. Ft.
1.STORM INAGE
IMPERVIOUS SQ. FT.5Lo X $0.192 PER SQ. FT.
2. SANITARY SEt,lER-CITY
NO. OF PFU'S
(See Reverse)
X $39.78 PER PFU
TRANSPORTAT iON
NO OF UNITS X TRIP RATE X COST PER TRIP
x - x $401.05
3
ADMINISTRATIVE FEES
BASE CHARGE (SUBT0TAL ABoVE) X .0s
SANITARY SEhlER-Mt,'lMC
NO. OF PFU'S
(Use PFU Total From Item 2 Above)
MI,IMC CREDIT IF APPLICABLE (SEE REVERSE)
$
$
SUBToTAL (ADD iTEMS 1,2, & 3)s qqsj
TOTAL-CITY SDC $ lol s:
$13.62 PER PFU + $10 MI,{MC ADMIN. FEE $
X
X
x $401.0s
x $401 .05
4
5
,-/-
TOTAL-MWMC SDC
TOTAL SDCKp Burdick
SDC Coordinator
0
g3
CITY OF OBEGO'U
SPrlTNGFIELE,
%
225 PTYTH STREET
SPRTNGFIEL,D, oREGoN 97477
INSPECTI0N REOUESTt 726-3769
OFFICE: 726-3759
1 P
L Dl"
City Job Nurnber6 [ i, f'rt
%
JOB DESCRIPTION
parmits are non-transferable and expireif vork is not started vithin 180 daysof lssuance or if vork is suspended for
180 days.
2. CONTRACTOR INSTALISTION ONLY
iilectrical Contractor
Add ress
ci ty_ Phone
Supervisor License Number
Expiration Date
Constr Contr. Number :.:-
Iixpiration Date
.'-lignature of Supervising Blectrician
0vners Name g
Add ress
CONPTTTE PEE SCBEDULE BELOV
Nev Residential-Single orHulti-Family per dvelling unit.
Service fncluded:
f tems Cos t
1000 sq.ft. or Less
Each additional 500sq. ft or portion
t hereo f
Each Hanuf'd Home or
-Hodular DveIling
Service or Feeder
$ 8s.00
s 1s.00
s 40.00
A
Sum
Ci ty Phone ? q/-2t/.?
OVNER INSTALI.ATION
The installation is being made onproperty I ovn vhich is not intendedfor sale, lease or rent.
Ovners Si
DATE:
B. Services or Feedersfnstallation, Aherationsor Relocation:
C
D
200 amps or less
201 amps to 400 amps
-over 401 to 600 amps
-0ver 600 amps or 1000 vo'Its
Branch Circuits
E
200 amps or less S201 amps to 400 amps
-
$401 amps to 600 anps
-
S601 amps to 1000 amps- Sover 1000 amps/volts
-
sReconnect 0n1y S
Temporary Services or'FeedersInstallation, Alteration or Relocation
.,00
.00
.00
ee nBu a5O-vE-
Nev, Alteration or Extension per panel
One Circui t 2-- S :S.00 35Each Addi tionalCircuit or vlth Servicg A ^/\or Feeder permi, _4_ $ .Z.OO :l-J'
Hiscellaneous (Service/feeder not included)
-Each installation
Pump or irrigation
Sign/0utline Lighting-
Limi ted Energy/Res
-Limi ted Energy/Comm
SUBTOTAL OP ABOYE
5Z State Surcharge
TOTAL
s0. 00
60.00
100. 00
130. 00
r00
.00
300
40
40
55
80
s
$
$
s
(^
s 40.00
s 40.00
s 20.00
s 36.00
BRECEIVED
ure:
5 (f-)
. ELBCTRTCAL PERHIT APPLICATION
..RESIDE] 'IAL..
22 s itoy,th sth stneeAPPLrcArroNl-''ERMrr
Springfteld, 1r,egon 97477
Building Diuision
7 26-37 53
>b Locaticn:
taeaoorc Map ll
t
SPNINGFTELD i4os I
Tcr Lot ll
bdivision:
Jne? :
ldre:t
additicn
Date of Applica
S
enera I
-) n"^oa"r
1 ,ourr",,o,o
DIL
Deaoyibe l{onk: \
fln* , kn{nsftctt rm
F/*
-B- 0 h,to
Value
1r s
lac<_
rD( ?l^,l4l.zzl9
oar
Iutnb 1ng
echanica
l,eccrical
uperv_isi.ng Dlec c r'.t ( !ll rr
t io +-he reoponoibi.lity of-tle permit ho-Lder to a6e that all inopsssi6^t are nada at thc propcr tine, that ocoh cddreaa is readab)enon tha street, anc that the pcymtt oavd is Located at the front of the otooertu.9uilding D'!vi=iot: ap7'ov'ed plan shcll renain on the Building sitc At atl' tihea.'
?ocspu?E Fon IN9PEC|I)N R9QUEST:CALL 726-3769 (rccorder) atate yout City Ceolgrated job nunber,zquestcl-ail u*n yoill be nnde the sarne
'u uill be ready fon inopeotton, Contractora or A.mers nana arul plone nwbcr.
dcy, requesta ncde after ?:00 on viLL be nada the ncat l,nrking
xruired fn:;oeetion:t
lottr City Deaigr.atad Job Ntnber fo:
job aCdteaa, type
Requeots veceiued
of inspec)ictt
before 7:00 cn
l
l
l
l
l
ercavation, but prior. tc set up of
forme,
UIIDERSLAB PLUiIEIIIC, ELECINICAL E
ilECHI.|IICAL: !'o be nade before anyl i[TiiZu"red.
FOOTING 4.F1UNDA?ICN: To be naCeafter trenches are ercauated atul
forna are erected, but prtor to
pouring ccncretc.
U!|DSRC!?OU!!D P!.Uil:t rNC , SSUTR . u.lTElU
DRAIllLGl: 'l'o be nal.e prlor to t'il-Tl{Tiinchre .
UNDERI'LOOR PT,UI.!DI:IC .1 I,IECIIANICAL:lto Ae naae priot,-io inetallation of
floor inaulcLion or decking.
1 posr nno atau: To be nadc prtot, to
) Tfu-talfi7ibibf floor insulation or
decking,
I NiU t,A',t' t 0N 1 vAl,oR BA ua !:R J ilslLclloil :DEtl)LIT-To b;;a{e after ulr-;nouktion dA
rcqu'Jred vapor ban'iera e)'e in plaoe
but beJ'ore any Lath, gypsta boayJ on
tnLL oouering io applied, crd before
ay inculation ia concealed.
DnYUAl,t. INSPEA'ION: ?o ba nada
fif"r. atTliiyuatfta in place,
but prior to any taping.
i!AS1Ntl!: Stccl Tocation, bond
tifrilgrcuting or terticala in
accordance uith U,B,C, Sectionqi1<
Sanitary aetter capped at propert'; Lire
Septic tork pwrped ad. fil,Led uith gratal
Final - l{hen aboue itena ate ccnpletccl
and uhen danalition ia oanplete or atru:-
turo nooed and, premisea aleaneC up.
Blooking atd set-up
Plunbing connectione -- oasar aru! uater
Elaotnioal Conneotion - Slooking, aet-u,
and, plwnbing conneotione trust be apprcted
baforc nequooting elaotrioal inepec:iott
Aooesaor; Building
'l'o be mtde aJ'ter
e
I , I.IDODSTO|/E:ly ccnuf;;a.
After inatallation io
CU4B & AI'PnQAql AP:\QN: After formo,il,e;t*be,J6;t pt"i;;' to pouring
concrete.
SIDI:tilf.K $ DRfVEILAY: For all con-
"re t. -p"vlrr,fi$fi; a trect tight-
of-rx:y, to bc made aften all erca-
uating canplete & fotn utork & eub-
base tmtertal in place.pcrchea, ekirt"Jng, decke,
leted.
Pinal, - Aftar
eto. ate oanp
ROt-tcil Pl,uil?I:!c. ELr:CrRlCA!, 3 MECII-
TnrcAL: No .",o;k-l; t;-;;"or*r;A'GiTthcse inspections have beer
made arul approuei.
FIPDPLNE: Pnior to plccir4 facingmctet'ials and bcfore franing inapec-
tion.
fW!tlc: l'tust be requeoted af!er
approval ol rough plwnbing, elcctni-cal & ncclanical. ALI roofing
bracing A chinncyo, etc. m,tst be
, conpletcd. llo uctk ta to be con-
. cacled until thio inspection lwa'been nade anC approved
FIIIAL PLUI,:DIIIO
F I II A L I'IEC I IA II T C A I,
IENCE: hthen cornplcte -- ProuiCe
gatei on novable sootiona tlnough
P, U, E,
AtL project conditiona, :tuch ao che i.natallat:.on of alroot traeo, conplation of the
re.quir.cd lantlscaping, cto., rmtot be aatiafiod bclore ths BILILDLNC FIt'lA\ c.an.be tequeote<l.
FINAL BUI:,DINC: 't'lte l'itrul Building frtopcotion nrot be nequeoted aften tho Final Plwnbinn
Elecbrical, anC Meclwrical Inepeotiono hqva been wde ard appt'ouad
P4te 1 of 't
FINAL ELECTNICAL
.At,I, I.IANIICLTS AND CLI:^NOUI'S IIUS'I'DT: ACCE:SSII]LE, ADJUSTIIENI TO DE TL4DE A? TIO COST ?O CI?Y
u
l
ll
l
JOB NO
7 of Lot Coueragc_
! of Storiae
Total lteight
Topogmplry
'BuiWing Pendt
State
Total Clangea.
Pltnbing Pernit
€tdte
Stcte
Total
Pertit laeuowe
l,leclanioal Penrit
?otal
SOLAP-TT.ICESS REQ.-L-CO G+
Bedroona
TNT TYPE ,
Interior''." ',
.
COnmen'r:rl
'
Panhandle
_ Cul-de-oao
[-ot Faceo -
-- Feea --
!leat
c;
t.oDe
Building Vqlue & Perm it
Thio V:rmit t'.o lranl:ad on tliia oipfeos corvl.ttion tlnL the tr,zid.cotrctrttc'Liott
ahall, irt atL raapccLi," "oi'tiiri-'to- l;ha orclinn;r:e :nlopt'o'! ltiy drc Ctty of
iruiihfirta, i.ncllud!no' tii zo"ing Crdinanc.'2, rc'lulcLtlvj Lha ac:rc1.t'tt"-l!."'.',,^
ird uon of LuiLdinge , ant! ma,y bo aucpendc'l or rcttokcC aL ctiy LLnc upon ulc
tation of arry prcuiaiono of aaid'Ordinarrces'
il k
)t
Datc Paid:
Reeeipt ll
Signed:
Mech<Inicql Permit
Plumbing Permit
No nercort oltall conntt'rtct, inalal!, alter or clvtngc -cny neu.cr e:isti-trg'ilrri^t't"g
"r}riii"oL ,yiton in tthole or in parh, inlcss cuch petcon ie tho
injal p"oaoesnon oi'o ,Lli.a pt"^tror'c Lic.cns'e, eaccpl; Llnt a pc:son nay lo.
plGttiii ,ork to propo.l'ty "itri"n ia ouned, Leascd ir opet'ated by thc app'Li-
cant.
Electricql Permit
llhere Stnta tan,t requit,o:t tlat tha cloctrtcaL uork be dona by .an Slect'rical
contnactor, tha ol)ch.ical porLiott of thts ponnit clnLl tot be ualic until
the Label lno bean oigned by the ElecLrical CottLraatot'
I
PLan [ranL,tct'
A
I IIAVE CAREFULLY DXAMINED the conpleted application fon permit, and do
hareby certify thal; aLL itfotru.tion hereon ie true and, corncct, anC I
f\trther certify thal; any ar.d aLL aork perfor.zcd ehal! be done in acoot -
dance with the ordinanceo of tlra City of Springficld, ad thc La.ta of tho
State of 0regcn psrl;aining to tlrc utork Ceacribcd hereln, cttd alat N0 1CCU-
PAtlCy DILL be nnde of any atruotur,e ui.thout, perniaeion of the Suilding Di-
vieiort. I furthct, certif;; that otly contractots at;d etplcileea ul:o are in
cmpliance Dibh cRS 701.1ss ui.ll be uaed on thie proiect
P. L,llouBe 6at aep-Accc{tg.
North
Elaa t
South
Hoot
trG x VaLuarTEM
I'ktitt
Ca'doe
Carpcrt
Accessoflt
rOTAL VALUE
S.D.C. I.5 r
CIIARGENO,FI:E
Fi.*twea
ReaidetrLial (1 bdth)
Sanitary Seuer
l,lctor
-
CHARGENO.FEE
Red. So, ftq,
Nau/Exterd Cincuita
Ternporary Serttice
ilc.FgE
P.ttttce EIU'S
bhant llood.
Vent Fan
l,lcodetote
-. ENCROACHMENT .-
7.
I I ',
. ,t
't,,/r rr',1r,' rl I l:.. r
Maintenance
Pcrmit
Curbeu!
-
sidp:,talk
fence
Electrical ta.bel
Mobile llane
16;, oo
l{tob t A2
A
t
A
Tdte
-
\\ \^(NN- \\onk^
tttttt
ITliM CIIARCE
Stato Suro,Vrae
Total Clarooo
TOTAL AMOUI.I:I DUE:'
Signed -
\
er