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HomeMy WebLinkAboutPermit Building 1995-09-28SPRINGFIELD RESIDENTIAI, PERMIT APPTICATION CITY OF SPRINGFIELD COMMT'NITY SERVICES DIVISION BUII,DING SAFETY Page 1 ilob Number: 951455A 225 North Fifth Street Springfield, OR 97477 Location of Proposed Work: 8057 THURSTON RD Assessors t"tap #: L7023602 Lot: Block: Office: Inspection Line: 726 -37 59 725 -37 69 Tax Lot #: 00206 Subdivision: CITY OF SPilNGFIEI^O, ONEGON Owner: ELAINA FISHER Address: 8067 THURSTON RD Describe Work: RESIDENTIAL ADDITION Phone #: 747-4876 ciry/srate/zi-p: SPRTNGFIELD, OR 97478 NEW QUAD AREA: 5RNE -- OFFICE USE .- LAND USE: 1111 To requests an inspection, call the 24 hour recording aL 726-3769. A11 inspections 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. --- REQUIRED INSPECTIONS --- FOOTING - After trenches are excavated. FOITNDATION - After forms are erected but prior to concrete placement. WATER LINE - Prior to fill-ing Erench. SAI{ITARY SEWER LINE - Prior to filling trench. ELECTRICAL SERVICE - Must be approved to obtain permanent power. FINAL BUILDING - I{hen all required inspections have been approved and the building is complete. ftem Main Garage Total Value Building Permit Fee Surcharge/admin TOTAI, FEE --- BUILDING PERMIT --- Square Feet x $/Square Feet Val-ue 800.00 0.00 800.00 15.00 L.20 (A)L6.20 PLI'I{BTNG PERMIT --- Item MINIMUM PERMIT FEE Plumbing Permit Surcharge/admin TOTAL CIIARGE (c) Fee 15.00 15.00 L.20 L5.20 --- MISCELLAI{EOUS PERMITS Surcharge/edmin SYSTEMS DEVELOPMENT ELECTRICAL PERMIT TOTAIJ MISCEIJIJAIIEOUS PERMITS 0 LL4 54 00 94 00 158.94(E) 20L.34(Excluding Electrical ) un1eEs otherwiae noted --- TOTAI, AIITOI,MT DUE --- (A, B, C, D, and E combined) SPRINGFIELD ,Job Number: 951456A ATT OF SPRINGFIELD, ONEGON Page 2 --- BUII,DING VAI,UE, PI,AIiI CHECK ATiID BUII.DING PERMIT --- This permit is granted on the express condition t.hat the said construction shal], in all respects, conform Eo the Ordinance adopted by the City of Springfield., including Ehe 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. -.- A.DDITIONAL COMMEMTS --- By signature, I Etaue and agree, that I have carefully e t.he completed application and do hereby eerEify that all xamined informaEion 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 Ehe Laws of the State of Oregon pertaining to the work described herein, and thaE NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I furt,her certify that only contractors and employees who are in compliance wiEh ORS 701.055 will be used on this project. I further agree to ensure that all reguired inspections are requested at the proper Lime, that each address is readable from the sEreet, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during construction. /r,/*{ ignature Date --- VALIDATION --- Receipt Number: Date Paid: th3qL8lq5 .cDt .otp rc1 ,q 7 q Q- *,N\fol\)\ rJ t Amount Received Received By 1 Addition is to be connected to existing structure by covered walkway or porch. Walkway/porch is to be completed within njnety (90) days of Temporary 0ccupancy. Until 1ega1 partition of the property is completed, structure is approved as single family residence only. 2 B CTS utceo e ^ ff\D0,*-, SPRINGFIELO q'RESIDENTIAL PERMIT APPLICATION lnspections: 726-3769 Office: 726-3759 LOCATION OF PROPOSED WORK: ASSESSORS MAP: LOT: h, JOB NUMBER 225 Fifth Street Springfield, Oregon 97 477 TAX LOT: BLOCK:SUBDIVISION PHONE zlPa-7/n STATE: OWNER: ADDRESS CITY: NEW -- FIEMODEL ADDITION DEMOLISH s111ss^- /y' Z Wa l& DESCRIBE WORK EXPI RES PHON EADDRESS L: CONTRACTOR'S NAME CONST. CONTRACTOR # GENERAL: PLUMBING MECHANICA ELECTRICAL: r OF BDFIMS: _ OFFICE USE - LAND IJSE: ZONING CODE: FLOOD PLAIN WATER HEATER: E OF UNITS: RANGE: SECONDARY HEAT: SQUARE FOOTAGE: OUAD AREA: # OF BLDGS OCCY GROUP: * OF STORIES: CONSTR. TYPE: HEAT SOURCE: To request an inspection, you rriust call 726-3769. This is a24hour recording. All inspections requested before 7:00 a.m' wlll be made the same working day, inspections requested after 7:00 a.m. will be made the following work day. REOUIRED INSPECTIONS Temporary Electric It=.(ough Mechanicat - Prior toL-l cover. Final Plumbing - When all plumbing work is complete. Site lnspection - 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 obtain permanent electrical power. al Mechanical - When all mechanical work is complete. Fooling - After trenches are excavated,Fireplace - Prior to facing materials and f raming lnsp. Final Building - When all required inspections have been approved and building is completed.Masonry - Steel location, bond beams, grouting. Other Foundation - After forms are erected but prior to concrete placement.Wall/Ceiling lnsulation - Prior to cover. Underground Plumbing - Prior to f illing trench.[--l orywall - Prior to taping MOBILE HOME INSPE TIONS Underlloor Plumbing/ Mechanical - Prior to insulation or decking.Wood Stove - After installation. Post and Beam - Prior to floor insulation or decking.tnseit - Aite:' firepiace aPProval and installation of unit. Blocking and Set.Up - When all blocking is complete. Floor lnsulation - Prior to decki ng.Curbcut & Approach - After forms are erected but prior to placement of concrete. Plumbing Conneclions - When home has been connected to water and sewer. Sanitary Sewer - Prior to filling irench.Electrical Conneclion - When blocking, set-up, and plumbing inspections have been approved and the home is connected to the servlce panel. Storm Sewer - Prior to filling trench. Sidewalk & DrivewaY - After excavation is complete, forms and sub-base material in Place. Water Line - Prior to filling trench. Fence - When comPleted Slreet 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. a 7?7- 4? 74, q- "78 *227 ,e) Er E E r E E E E E I Framing - Prior to cover. tl E tlE Lot faces Lot sq. ftg. Lot coverage Topography Total height Lot Type - lnterior - Corner - Panhandle - Cul-de-sac Set l(s IS THE PROPOSED WOFIK IN THE HISTORICAL DISTRICT, OR ON THE HISTORICAL REGISTER? - lf yes, this application must be signed and approved by the Historical Coordinator prior to permit issuance. APPROVED: P.L,GARHSE ACC N S E VALUE (A) X $/SO. FT. Total Value Building 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. Receipt Number:- Plans Reviewed By Date Plan Check Fee: Date Paid Fleceived By SYSTEMS DEVELOPMENT CHARGE (SDC) (B) 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) N0 FT. FT. FT. PLUMBING PERMIT Plumbing Permit State Surcharge Total Charge ADDITTONAL COMMENTS Wood Stove/ lnsert/ Fireplace Unit Dryer Vent (D) NoVent Fan Mechanical Permit lssuance State Surcharge Total Permit MECHANICAL PERMIT Fu rnace Exhaust Hood By signature, I state and agree, that I have caref ully examined the completed application and do hereby certlfy 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 contiactors and employees who are in compliance with ORS 701.055 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 natu re Date ron.on the s;te at all tirncs d'-;rin 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 Combined) D I VALIDATION RECEIPT NUMBE DATE PAID AMOUNT REC RECEIVED BY I AIa4U OFEGO'VCITY OF SPR 1 ON Permi ts are non-transferable and exPire if vork is not started vithin 180 days of issuance or if vork is suspended for L80 days. 2.COMRACTOR INSTALI.,ATION EIect I Contractor Address Ci ty Phone Supervisor Li s ber Expi ra t ion.te Cons tr tr. Number Exp at ion Date ture of Supervising Electric 0vners Name Address Ci ty Phone OVNER ALI..ATION The installation is being made on property f ovn vhich is not intended for sa1e, Iease or rent. mttted has the { speci{ic land use ELECTRICAL PERI{IT APPLICATION Ci ty Job Nurnber COHPLETE FEE SCEEDTIIJ BELOV A Nev Residential-Single or Multi-Family per dwelling unit. Service Included:ftems Cost $ 8s.00 SPrrINGFIELD 1000 sq.ft. or less Each additional 500 sq. ft or portion thereof Each Manuf'd Home- or Modular Dvelling Sertice or Feeder J t..i.rt not requiia 225 FIFTH STREET SPRINGFTELD, OREGbN 974 INSPECIION REQUEST:.. 72 OFFICE: 726-3759' -fg --15 A&horized Sum $ 1s.00 s 0040 B Services or Feeders Installation, Alterations or Relocation: 200 amps or less \ 20L amps to 400 amPs _ 40L amps to 600 amPs - 601 amps to 1000 amps- Over L000 amps/volts Reconnect 0n1y Temporary Services or Feeders Installation, Alteration or Relocation 200 amps''or less $ 40.00 over 4b1 to 6oo amps - $ Bo.oo 0ver 600 amps or lbOO voTts see 'Bu a65iE- Branch Circuits Nev, Alteration or Extension Per Pane1 ' s s0.00 s 60.00 s100. 00 $130.00 s300.00 $ 40.00 s c D One Circuit $ 35.00 Each Additional Circuit or vith Service or Feeder Permit $ 2-00 E. Miscellaneous (Service/feeder not included) -Each installation Pump or irrigation Sign/0ut1ine Light ing_ Limited Energy/Res Limited Energy/Comm SUBTOTAL OF ABOVE 5Z State Surcharge 32 Administrative Fee TOTAI $40 $40 $20 $36 00 00 00 00Onryers Signature fur,^V4, 5 DATE: RECETVED B @ '!Ft-+ 11r: t.'. 1. LOCATION OFnotn INSTALI,ATION approv al Zonin 225 FTFTH STREET SPRTNGFTELD, OREG0N 97477::4' -- INSPECTION REQIIESTI 726-17.69l;.;.i tr'r,-rn,'' OFFICE: 726-3759 SPRIi.GFTELE' ELECTRICAI PERHIT APPLICATION b Nunber Q=t tll n(o 3. COHPI,ETE FEE SCMDI'LE BELOII A Nev Residential-Single or Multi-Family per dvelling unit. Service Included:Items Cost 1000 sq.ft. or less Each additional 500 sq. ft or portion thereo f Eaeh Manuf'd Home or Modular Dvelling Servi.ce or Feeder s 8s.00 s 15.00 s 40.00 B 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 0n1y $ s0.00 s 60.00 s100.00 s130. 00 s300. 00 $ 40.00 c 200 amps or less 201, amps to 400 amps -Over 40L to 600 amps Over 600 amps or 1000-l6l-[s --lra ,, u ,ldI LEGAL DESCRIPTION JOB DESCRIPTION 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 INSTALI.ATION ONLY ElectricaL contractor 0riE$0li ILEIIRIC S[RYitE Address \>,--, (5o*-.a., ss&s43-wt 6cl.r -s Sum Ci ty on Expiration Date /O ' Q(u Constr Contr. llumber clo4G C- Expiration Date q -qLD re of Supervising Electrician Temporary Services or Feeders Installation, Alteration or Relocation Supervi sor icense Number Signafu 7l*011*,'r '1 SUBTOTAL OF ABOVE 52 State Surcharge 32 Administrative Fee TOTAL 40.00 55.00 80.00 ee *8" aEF -<- s s $ s Ovners Address Ci Phone OgNER INSTALLATION The installation is beihg made on property f ovn vhich is not intended for sale, lease or rent. Ovners Signature: DATE:ID- lo - D. Branch Circuits Nev, Alteration or Extension Per Panel one circuit I S 35.00 1lf.}" Each Additional Circuit or vith Service or Feeder Permit S 2.00 E. Miscellaneous (Service/feeder not included) 5 He{.- -Each installation Pump or irrigation S Sign/Out1ine Lighting- S Limited Energy/Res $ Limited Energy/Comm S 40.00 40.00 20.00 36.00 C'TY OF OFEGSIU RECEIVED 5 ?<> funr, &o-, 04 Pil wlnato o (//4/ .u xrr!fi lkj, tAat full ?7/77 u Aurr,Angl Otu/ U ltwd fl"u a/)4/ rul.ualu -/dw 4 V Jl,ll/L /ruld- ,,t0 td4/ U,e, *nptt;"&, Jfiat t u EIBNI vt. FtsuER, M.s. Oregon Teacher Certification ;A.Ullr+-a/nd lua-fu, r4,0//l/LJWtCta, jgil*Jntlril,u 4/nd.a/rld. du, tjarr* W /* fur,,tu Handicapped Learner II . . t Wr" ioL-$dq Home 747-4876 Cellular 954-1352 I i ) TENTATIYE PARTITION MAP FOR ELEI'{A FISHER, N.W. t/4, SEC. 36, T.175., R.zYr., W.M. SPRINGFIEI,I, IANE COANTY, OREGON AUGUST 4, 1995 SCAI-E 1' = 100' I ,o 6o ZONNG: LDR . LOA D€'IS7Y R6SDEI{II4L TE PROPERrY fO IIE YEST 6 ZOA€O L'X, II€ frffiRty to ,)€ Easr ,s zot€o cRto. ft€ PRe€Rff 70 I}€ SOiJTH 'S L.o.R, AAO @'O. TI€ PROPERfY TO Ir€ ^rof,rH E ZO €0 Eru DASTNC USE: SN6LE FAI.I-Y PI.OODIIAY: SASED OrV FW DAI!. COr,f{UVrv PA|€.L Na. 4t559t 0390 c. DECE^/EER 18. 1945. InS PROPERIY rS il zot€ c Ato 6, ,ELL o(/I8DE fE tOO YEAR FLO@yaf. IE PRoPERTY TO TT€ 'VORTH 6 PARIIALIY N ZAt€ A" SOIAR STATEMENT: nrs DEv€toPr€Nr r'€rs saaR accEss 5IAfDAR06 P6R clry oF spRryc.FElo otvttde*rm cox J4.ato til t. r4 l OINER E APPUCANT: ELEM At F6r€A 8067 ft,.Rglo|l RoaD sPR \(jF€LO. 6 37476 DESCRIPTION: t7-o2-36-2 fL ?O5 EIEYATIONS BASED ON: OTY 6 ffitJG.'ELD OAIW LEGEND + o PRoPEBTv coRr{ER A -* OERHEAD POv€RLtlE ts URAAN CROYIH SAAD^RY NETRO PLI.N DESIGNITIONT LDR . LO' O€NgIY RESO€I/rtrL 7|€ PROPEnTY rO f t€ t,cfif H 's zoi€o l6*,cLL rtt!|. ItE PRffiRtY lo fr€ €asl lS Zoi€o R(faL REP€Nttal- IlE PRoPERTY IO 7T€ YESI 6 L'.R, o l 0 n. ggEfr PARCEL I 5.O ACRES tr I o oi a I I + iz-?/tr $t' i POrER Pd.E IREEg 6Rorr't0 ELtvaT,ov itt itt Irt ,ltl trEK!6f ts,I VICINITY MAP t tooo' u PBOJECA: TENIArIVE PARTITION MAP TAX MAP 17-02-36-2 TAX LOT 206 CUE}{l: ELENA M. FISHER A067 THURSTON ROAO sPRrN6FlEL0, OR 9747A DlrRTNSIONS IOGI PAR& W 3mxa. lorZ E-rEm#Esro L&O SUVerd oAD L 9ROn Epn€8 0€c lr. t995 Branch tlo X. 6B lud Sp.batl.l4 &.F. naz (e3) ?aa-st d ls) ?aafl DvG D\S\95166\9rA61EWrc a-JO-% AN t E N1 -i-o Date From of Phone I uncew WH YOU WERE OUT A.M. P.M. Area Code Number Ext. Fax Area Code Number I 0- Please callI@ilVre@@rE@IE@EEIEI@ III Signed Ouill Corporation. Be-order Number 7-92001 \ RFSIDENTIAL PERMIT APPLICATION lnspections: 726.3769 Qf fice; 726.3759 \ LOCATION OF PROPOSED WOFIK: SPR rxcrrelE zfr,fus7 7i*.ffaaJ E JOB NUMBER 225 Fif tlr Street Springfl etcJ, Oregon g7477 ASSESSOBS MAP:17-oL--oL TAX LOT;7e 6. LOT:BLOCK: PHONE; STATE:ZIP: 7u <,t 7 CITY: OWNEB: ADDRESS: ADDITION DEMOLISH OTHER OESCBIBE WORI(: NEw X BEMoDEL ADDFESS l)ONEIRES . PH a-Z/e, atl CONTBACTOR'S NAMI-: G EN EBAL: PLUMBING: MECHANICAL: ELECTRICAL: CONST. CONTRACTOR / - OFFICE USE - LAND USE: ,f OF UNITS: QUAD AREA: - I OF BLDGS: FLOOD PLAIN: ZONING CODE SECONDARY HEAT: SOUARE FOOTAGE; , OF BDRMS: OCCY GROUP: E OF STORIES; CONSTR. TYPE: HEAT SOUBCE: WATER HEATER:___RANGE: Fool To rcquest an rnspection, you must cail 726.376g. Thrs rs a 24 hourmade thc sante worklng day, lnspections rcquested aftor 7;00 a,m. rccordlng. All lnspecilons requosted before 7:00 a,mwlll bo macle the followlng worl( day. REOUIRED TNSPECTIONS l--l Tornporary Etectric Slto lnspcction - To be macloalter excavatlon, but prlor toSettlnO forllts. Foundallon - n ftor forms areerocled but prlor to concreloplace,nont. U n der Plumbing/ Electrical/| - Prlor to cover.ca - A,ter trenches are led. Masonry - Steel locatlon, bonclbeams, grouilng, Rough Mechanlcal - prlor tocover. Rough Eloctrlcal - prlor tocovcr. Electrlcal Servlce - Must beapproved to obtaln permanent clectrlcal power. Flroplace - prlor to faclngmaterlals and framlng lnsfl Framlng - prlor to cover. Wall/Colllng lnsulallon - prlor to I-_l FInat ptumbtng - When ail - plumblng worl( ls complete. [-_| Flnat Eloctrlcal - When ail'- electrlcal work ls complote. Flnal Mscharrlcal - When allmechanlcal work ls complete, Flnal Bulldlng - Whon altrequlred lnspecilons have beenapproved and bulldlng lscompteted, wlll be Othor cover, [-l Underground plumblno - priorr-J to flllliq rrcnch [-l Drywall - prtor ro raptng. Underlloor plumblng / Mcchanlcal - Prlor to lnsulatlon or clecklng. Post and Boanv. - prlor to lloorlnsulallon or docklng. MOBILE HOME INSPE TIONS Plumblng Connoctlons - Whenhomo has been connected towater and sewer. Floor lnsulatlon - prlor todecklng, Rough Plurnbing - Prlor to cover. Wood Stovo - After lnstallatlon. Curbcut & Approach - Afterlorms are erected bUl prior toplacomont of concrctc. Streel Troos - When all roqulredtroes aro plantod. [--l tnsert - After flreptace approval - and lnstallailon ol unlt. [--l Btocktng and Sot.Up - When ail - blocklng ls complete. l-_] Sarritary Scwer - prior ro ililtng.J lrench. Storm Sewer - prior to fllllngtrench. Sldewalk & Drlveway - Af terexcavatlon ls completo, lormsand sub.base materlal ln place. Electrlcal Connoclion - Whenblocklng, set.up, and plumblnglnspections have beon approvedand the home ls connected lothe servlce panel,Water Llne - Prlor to f llling trench.Fenco - When completed. Flnal - Alter all requiredInspectlons are approved andporchos, sklrtlng, decks, andventlng havo been lnstallod. tl E Lot faces Lot sq. ftg. Lot coverage Topography Total helght Lot Typc - lnterlor - Corner - Panhandle - Cul.de.sac . HE PROPOSED WORK tN THE HISTORICAL DISTRICT, OR ON THE HISTORICAL FIEGISTER? - lf yes, thls applicatlon must be slgned and approved by the Historical Coordinator prior to permit issuance. APT)ROVED P.L.HSE GAR ACC N S E VALUE (A) I X $/SO, FT, Total Valuo BUILDING PERMIT ITEM SO, FT. Maln Garago Carport Building Permit Fee State Surcharge Total Fee BUILDING VALUE, PLAN CHECK AND BUILDING PERMIT Thls permlt ls granted on the cxpress condition that the said constructlon shall, ln all respects, confortn to the Ordinance adopted by lhc City of Spring(lclcl , includlng the Development Code, regulating the coostruction and use of bulldlngs, and may be suspended or revoked at any time upon vlolation of any provisions of said ordinances. Recel pt Nurnbcr:---.. - Date Pald Received By 7 Plan Check Fee SYSTEMS DEVELOPMENT CHARGE (SDC) (B) Systems Developmcnt Charge ls due on all undeveloped propertles wlthln tlrc City linrits whiclr are being lmproved. Resldentlal Bath(s) Sanltary Sewer Water Storm Sewer Moblle Home PERMIT FEE N0 (c) FT. Plumblng Permlt Stato Surcharge Total Charge PLUMBING ITEM Flx t u res ADDITIONAL COMMENTS Wood Stove/ lnsert/ Fl roplace Unlt Dryer Vent (D) N0Vent Fan Mechanlcal Permlt lssuance State Surcharge Total Permlt MECHANICAL PERMIT Furnacg Exhaust Hood By slgnature, I state and agree, that I have carcf ully examlned the completed appllcation and do hereby certlfy that all lnformatlon hereon ls true and correct, and I f urther cerilfy that any and all work performed shall be done in accordance wlth the Ordinances of the City of Sprlngf ietd, and the Laws of the Stato ol Orcgon pertalnlng to thc work described heroln, and that NO OCCUPANCY wiil be macJe of any structure wlthout perrnission of the Butldirrg Safety Dlvislon. I further certlfy that only contractors and employees who are ln compllance with ORS 701.05S wlll be used on thls prolec t. I further agree to ensurc that all requlrecl Inspectjons are requested at the propor tlme, that cach address ls readable from tho street, lhat the permlt card ls located at the f ront he approved set of plans wlll remaln s durin con s ,, Slgnature Date ction of the propert on the slte at MISCELLANEOUS PERMITS Moblle Home State lssuance State Surcharge Sldewalk - ft Curbcut ' (, Demolltlon State Surcharge Total Mlscellaneous Permits (E) TOTAL AMOUNT DUE (excluding electrlcal) (A, B, C, D, and E Comblned) VALIDATION: \ BECEIPT NUM R DATE PAID AMOUNT RECEIV BECEIVED BY \}Ntr !tr Ptans Prcvl-ewccl-By-Date FT. - FT. F Pr-r Tr F PT S r-:r-rNsl TPI lr--TnN F1!a! !;61U7r:!t-, tNt{)t7'. v,/ Authorizctlon to Proceed AEreement Page 4. 8E}-iitiE srGt',ING THiS AGREDIIENT, pt,EASE READ TND UIIDERSTAIID THE I'lDrrl'lrlJG 0F t;'"t:ir PAJ1AGRAYH OF THIS 6GREEHEI{T. IT A}'F'EC'[S YUUR INIERDSTS 1I{ THE PP'OPERTY A]JO' J .r'rjE uvEr{T oF DEFAUI,T, 1T pLAcEs you PEES0NALLT AT Rr st( At{t) THn suBJEcr PROI'LF" ..,t.Ht5K 0F FORECLOSURE !'UN C0S'fS AND EXPENSES INCUITJIf,D BY THE CITY IN Eiifolc]i. THE TERHS OF THIS AGREEHETIT. IN ?HE EVENT THAT YOU DO ITOI'U}IDERSTA}JD AltY'I :hHi 0i coHpruoNs oF THrS AGREEHEN?, PLEASE SEEK ANy Lr,l(:AL oR oursrDE oPtllIoNS Y"r' HAY"DESIRE. A}PLICANT('ITY City of Springfield i Nt ltsyrContractor Building Offrclal Business l{ame IL Add ress Eo(, / \-lt0R (J IJ CC Registration {l'j6 T"A,I'ID/PROPTSTT OIINER (s) T/VE HAVE READ THE ABOYE AUTEORIZATIOI{ TO PROCEED AGREEHDI'M.1/VE UNDERS]AN.] UIIA'I T? EXPRESSES A}TD THE RESPONSIBILITIES IT FLACES UPON US AS THE LA]TD/PROPERT Y O\NER.q. I/UE BE BOUND TIY ALL TERI'IS AI{D COI{PI'IIOIiS OT 'I HF: AGREEHEI'JT. llamo ItJd res s ulu fr*6J/u*od 'Y-, {..f- ?J/a/ t--.ii\j:,t-\'.'i:1. a Ai?P ;:C'Ve) /..t TCr Ft lL)o t' . t\-'t t-\rs./^Y\' L./. r'-. i i'l=i:::: l;F Ct-iY ATTDi'i1'ju-\' ,.1.t., .' t.,-..r: 1,'.tri--[-D U j - -- r.(,\-' r-nl ?r* ?ea 36s?