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HomeMy WebLinkAboutPermit Sewer Connection Record 1988-05-23..RESID.=NTIAL.. Zzs North rrt, irrnff"'cATtory/PgRt/ffr SprLngfteld, 2regon 97477 ButLding Diuiston 7 26-37 53 SPFlI]{GFIEL.D Signed L (*rrt*o # 53cnJob Locaticn: * /- aV-ze -z ,rot Ipt # O/gAAasessors Map Svbdirsision: 1/^ € /V. Zzttra 2a1 6'h ehone:776-7lSAAddress: 5rrcb. - oR.City:zip:272? Coryyez r F,xta2 -5.f; fu*Pszz.eG OtryrvF7 Sauq Ddte of Oppttoorl", f-2% Describe l,loyk: TI Value Add.itian RenoCeL eoiinacio"s Adlress GeneyaL r-t ia the responaibi-Lity of the pentrit ltoldet' to aee that aLL inapeetions oe nade at the prope! tiile, that each address is reqCahlefron the etneet, atd that the petmit card ia Located at the frcni of the otooerht.*Building Diuici.on approted pLot sTtcLL remain on the Bunlding site'at aLL' tikes." ?RoC DUPErF04 IySPEC2I)N.E!-37ES?:CALL726-3769(reeorder) state Aou? City desigrated job ntniibet,, job aCitess, type of inspecti.cnreQuested and uhen you uiLL be ready foz, inspection, cont?aetors oir a,tners nane'and plaie number.' -p.equests reLeii:Za iefcri 7:00 az'*'iLL be nade the eane dcg, tequests-made aftez, 7:00 att urLLL be nade the neat uotki$ day. Conatm.ction Lende? Raatt'narl Iout, City Desi.gtated Job thttnbez, rs: . 88O/V7 SITE INSPEC?ION: etcansation, but ?o be nwde aftet,prtor tc set up of INSULATTON/VAPOR BARRTER IIISPECTTON: To be made after aLL insulaticn e..d. required uapor berie?s @e in pl,ace but before otg la.th, Wpsun boatC or tnLL cooeying is applied, and. before oty ittsulation is concealed. DRYWALL INSPECII)N: Tc be nade@A-AT@;;n'is in plnce, but prior to ang taping. ILASONRI: Steel Location, bond beans, grouting ot oerticals in accotdqtce LtLth U.B.C. Section 24L 5. WO)DSTOVE: After installation ie antpleted. CARB & APPR1ACH APPAN: Aftet fonnsd.;-;;;;tAEtVGol, to pounng concrete. SIDE|ALK & DR|IEWAI: For aLL con- erete paoing uithin styeet right-gf-txA, to be nade after aLL erca- oating canplete & forn uork & sub- fu,se matet"ial in place. DEI.IOLTTIO]] OR !1OWD BUILDIIICS Sanitatg seoet capped at properfil Line Septic tank putnped cnd. filled utth gratel Final - l(hen abcoe itens ate ecnpleted and uhen Cqoll tion is eomplete o! st"uc- ttu,e notsed otd prewises cleaneC up. Hcmes Blockittg otd Set-ttp Plutrbing cormections -- aaie? atd, uater Eleetyical Cotnection - Bloektng, eet-up ard plmbing conneetions tntst be apprcxed. before requesting el,ectrical inspeetion Aceessory Building aNDERSLAB PLUMBIN?, ELg1TRICAL & WCH{IIICAL: ?o be made befoz,e anytlotk is cooet,ed, FO)I|ING & F)UNDA?TCN: Io be naCe 7f te!-rel,t"enc@ercauated.and forns are erected, but prior to Wuz.ing ccnc?eta. fi urogncnoultD qLUMETNG rffi w.,trsn.L)Lir4 trenches. UIIDEP,FLOOR PLUT,ETNG & I,IECIIANICAL : floor insulation or decking. POST AND BEAI,I: To be made pr.Lot, toGl&TffiTof ftoot, insuT)tion ot deckitrg. ROUGH PLU-IBII;IG. ELECTRICAL & MECH: ANICAL: No aotk is to be co.^et,edffilTthese inspections lntse been nad,e cnd. approoed.. ET.D.EPI,ACE: PrLon to placirg facingma.terials and. before ftaning inspec-tion. PRA,l.lfNG: ltust be requested after apptooal of rough plwnbing, electti- cal, & neclnnical. ALL roofittg bracing & chhrmeys, etc. nrast be . cornpLeted. Ito uotk is to be con- ., cealed until this inspectton has'been nade anC approued. fomns FTNAL PLUAAIM FIIIAL MECHANICAL FINAL ELECTRICAL of Fitnl - Aftet, etc. ate e,cnrp, pa,ehes, skirting, decks, Leted. IENCE: gates P.U.E. h*ren conplete -- ProuiCe or mortable sections through ALL project conditions, such as the installation of street tnees, conpletion of the required landsccping, etc,, tmtst be satisfied befoTe the NIfLDING FLNAL can be z,equested, n F|-NAL BUTLDTN|: The Final Build,ing rnspection nruEt be requested after the Final Plwnbing \J Eleetnical, otd. Mechanical fnspections haoe been nade atd approueC. K *ALL ILANHCLES AND CLEANOU?S TIUS? BE ACCESSIBLE, ADJUSTIIEI\I TO BE I,L4DE AT NO CCST TO CNY Page 1 of 2 {'/ Date: Z JoB No.8ga 3> SOLAR ACCESS REQ.- TotaL L-CO d Bedtooms: {. -l-z z-ga - f HAW CAREFULLy EXAMINED thz eornpLeted applieation for permit, and. do hereby cettify that aLL information het,eon is true and. eorreet, anl I fut'thet, cettify that anA ar.d aLL aork perforned slwll be done in accor- dance ttLth the Ordinances of the City of SprLngfield, and. the Las of the* State of Oregon pentaining to the uo?k Cescribed herein, en"d. that N0 )ccu- PANCY LrLIL be tnde of anl stlucture uithout permission of the Building Di-uision. f further certif'g that only eoilt?acto"s ad. anplcyees uho are in eazplianee uith ORS 707.055 uiLL be used on this project 5-zs-ff Crc Lot Faees -Enerqu Sources ?uoe Setbaeks lteat Df House Cataqe Aceess.Water, lleatet Not,th East FirepLace South lloodatoxe fa+ aa D+- % cf Lct C-"rog.:- LCT ?WE _ Intetict _ Corner _ Panltand.Le _ Atl-de-sac # of Stories Total Height lopogrqhy West -- Fees -- Building Volue & Permit This penn t is granted on the etpress condition t?at the said eonstructionslnll, in all respeets, conforn to the Cr&incnce adopted t)y the City of Springfteld, including the Zoning CYdinatce, regulating the ecnsttaeticn and use of buildings, antd may be suspend.ed or reuokeC at cnu time upon o.lc- lntion of dnA prcttisions of satd }ydinances. TOTAL VALUE D-+^ D-;5. Signed: X VaLue S.D.C. 7.5 r Building PermLt ?otal Clanges State Plumbing Perrnit No pereon shall construct, instal?., altet' or cltange anA ned cr eristing plwnbing or dtainage systan in ulole ot in part" ztnleee sueh person is the Legal possessor of a oalid plutnber,ts Li,eense, e.ccept tlnt a pe"son may do plunbing uork to ptope?tA uhieh is otmed, Leased or operated by the 6ppli.- eant. /N-lzaa- af .*>a=s.>z@7 ,{sa ?f"a *W 4.2. --- '/ N0.FEE CHARGE @ ea Fi.rtut,es Resid.etttial (1 bath) Plwnbing Perrrit Electricol Permit Where State Lan requires tlat the electyical uork be done by an Eleetrical Contraetor,, the eleetrtcal portion of this pernit slwll not be oali.C until the Label lns been signed bg the Eleetrical Contraeto!. L PermLt IotaL lla,t/Eetend Circuits Set uice CIIARCE llcodstotte * Mechqnicql Permit bhanat HooC Vent Fot Pentnt fssuotee Meelwnicel Per,nrtt lgcrity Deposit Sto?age Mainterwnee Perttrit Cvtbcut Sideualk lence EZeettical la.bel Mobile Hotne TOTAL AMOUNT DUE:*fr 3/-e Signed Date rTEM Sdnitdnt Seuer Watpt NC.FEE FLtrnacc PTll I s ?otal Charoes State Swehayqe KN0W ALL MEN BY THESE PRESENTS, that the undersiqned, hereb.v called erantors, are_hereby declaring that the follow'ing described nrooerty is a oermanentutility easement: DECLARATION OF PRIVATE EASEMENT The West 3 feet of the East 6 feet of Lot 11 First Addition to E-Z Living Estates as platted and recorded on Page 16 of Book 70, Lane County 0regon Plat Records, in Lane County, 0regon. tt stiitl be thb obii'gation of the'grantee to restor.: th. prop grantor.to original condition immed'iately upon completion of performed in the private.easement erty of the any work The easement sha'll be used fbr the maintenance or replacement of utilityfacilities serving the following.described property: Beginning at a point 2276.56 feet North Oo OI' Westfrom the Southeast corner of the Jacob Halsted DonationLand Clain No. 47, Township 17 South, Range 3 West ofthe Willamette lleridian;. running thence West 330.22 feet;thence North 0o 01r West 65 feet to the true point ofbeginning, thence West 235.0 feet to the East line of5th Street, thence North 60.0 'feet, thence East 235.0feet to a point North of the point of beginn irg, thenceSouth 60.0 feet to the point of beginning, 85 feet thereof. in Lane County, Oregon EXCEPT the east STA 0F0 ss. County of Lane . BE IT REI4EI"IBERED, That on this the undersigned, a Notary Public in appeared the within named known to me to be the iden ca fiay or and for sai l9&? , before me, State, personally v unZ V ua cri n nd who execu e within instrument and acknowledqed to me thatfuli=l executed the same freely and voluntarily. . IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal the day and year last above written. H.y Commission expires : /(l t+A] 1) (i. (I' c), ,,, '/ t) t | ). l ,rl -)\\ .', \ .' ) ) I ta rY u c or regon b - //-48 t 8821169 CITY OF SPRINGFIELD IMPROVEMENT AGREEMENT AND APPLICATION FOR SEWER HOOKUP l,le, the undersigned property owners, request permission to connect the following described property to the sanitary sewer owned and maintained by the City of Springfield. }Je therefore agree to pay a charge 0f.170 per square foot of the benefiting property forthe first 150 feet of depth as a deposit against future assessments for sanitary sewer. Tax Lot No. /7 OU 2 t^ 2_ I /8m Receipt No. 162, b fizee? Beginning at a point 2276.s6 feet North 0o oil westfrom the Southeast corner of the Jacob Halsted, DonationLand clain No. 4'l, Township 12 south, Range 3 west ofthe Willamette lleridiani. running thence West 330.22 feet;thence North 0o 0rr west 65 feet to the true point ofbeginning, thence west 235.0 feet to the East line of5th street, thence North 60.0'feet, thence East 23s.0feet to a point North of the point of beginning, thencesouth 50.0 feet to the-po1nt qf beginning, in iane county, -Oregon. . EXCEPT the east 85 feet thereof . :. t:rr : it ,-1 ; t,; 1::i: .. : , i ' : r:t This agreement does not include the cost of a house connection to said City sewer, sewer user charges, connection fees, plumbing permits or other such costs to be assumed by theproperty owner. The applicant agrees to waive all right to remonstrate against an improvement project fc santiary sewer to be duly initiated by the City Council, but not the right to protest the amount or manner of spreading the assessment thereof, if the same sha'l'l appear to Applicantto bear inequitably or unfairly upon said property of Applicant; NOI,I THEREF0RE, the City agrees that if App'licant complies with the terms of this agree- ment and with all other app'licable laws of the State of 0regon, Lane County, and the City, the said Applicant shal'l be entit'led to connect the existing residence to the public sewer systems The covenants herein contained shall run with the land herein described, and shall be binding upon the heirs, executors, assigns, administrators, and successors of the parties hereto, and shall be construed to be a benefit and a burden upon the property herein describe This agreement shall be recorded in the Lane County Deed Records. WHEREFORE, the parties have set their hand and seal this fuQday ot ,ilazt legtr 5 -TCITY OF SPRINGFIELD APPLICANT /)J Jr o STATE OF OREGON COUNTY OF LANE 'tc s ss. r Pub 0n thi t 2^O/ a above document. ay of My conrmission Expires /- 8: 8Z For Fi nance Department Information:g Lateral Sewer 9 there personally appeared bqfole. me and signed the .: /530, OOTrunk Sewerc/s ED 120 REV 2/81 ,/- y'se 3-fr 0-l,a /-4f6 8821169 tl |l / ,( State of Oregon, CountY of Lane-ss' L the County Clerk' in.'rnd for the said [.,r.,u,'Ji' irerehy certify- that the within :;i;;#";i *is rJcel'cd.t.r rectrrd at 31 I".'tY t3 1C: 16 n""r 1516R Lane CountY OFFICIAL Records' Lane CountY Clerk a c3Nhrl. o)(D By' t' ( ?9o? rve €& >7. CITY OF SPRINGFIELD IMPROVEMENT AGREEMENT AND APPLICATION FOR SEWER HOOKUP We, the undersigned property owners, request permission to connect the following described property to the sanitary sewer owned and maintained by the City of Springfield. }Je therefore agree to pay a charge of.17d per square foot of the benefiting property forthe first 150 feet of depth as a deposit against future assessments for sanitary sewer. Tax Lot No. /7 oJ 2 b Z I /8@ Recei p t No. //56>, h fiue* Beginning at a point 2276.56 feet North 0o 01' Westfrom the southeast corner of the Jacob Halsted, DonationLand Clain No. 47, Township 12 South, Range 3 West ofthe willamette lteridian;. running thence west 330.22 feet;thence North 0o Ort west 65 feet to the true point ofbeginning, thence west 23s.0 feet to the East rine of5th Street, thence North 60.O teet, thence East 235.0feet to a point North of the point of beginning, thencesouth 60.0 fegt.to the-go-int gf beginning, in iane county,Oregon. . EXCEPT the east 85 feet thereof. This agreement does not include the cost of a house connection to said City sewer, sewetuser charges, connection fees, plumbing permits or other such costs to be assumed by theproperty owner. The app)icant agrees to waive all right to remonstrate against an improvement project fcsantiary sewer to be duly initiated by the City Council, but not the right to protest the amount or manner of spreading the assessment thereof, if the same shall appear to Applicantto bear inequitably or unfairly upon said property of Applicant; NOI^I THEREF0RE, the City agrees that if Applicant complies with the terms of this agree- ment and with all other applicable laws of the State of 0regon, Lane County, and the City,the said App'licant shall be entitled to connect the existing residence to the public sewer systems The covenants herein contained shall run with the land herein de-scribed, and shal'l be binding upon the heirs, executors, assigns, administrators, and successors of the parties hereto, and shall be construed to be a benefit and a burden upon the property herein describe This agreement shall be recorded in the Lane County Deed Records. WHEREFORE, the parties have set their hand and seal this ful day of Ha..letrR CITY OF SPRINGFIELD APPLICANT 6 a STATE OF OREGON)- ) couNTY 0F LANE ) 0n thi , Z-Ort auy o above document. ro Pub c ss. f C/"otz"z- { there personally appeared,before me and signed the.\, ' t 'l,, ,,.- ' i' ; My cornmission Exp ires: /-S-A7 For Finance Department Information: Trunk Sewerc/s ED 120 REV 2/81 ,,) tLateral Sewer # tsso, oo \ t/ 9 -Er\-;' x r4.Z ..I i.tf4 t t I 't tr: rlqrrl''fi{ v x4x -aA,u 445.2 6D5 xUI =r I x r-'/oilj,x o8[? c x- { -.,r. ] L aoe ^l )t'I Kx 444. I Jt .to 4S 4q4.7 x )o O o x 445.5 x 445.E i] ?n(e 1(cI I I .:r(.,OoGl5'tI f gq, 4449 Xco MH +73.5 0' I 4x L', ) o ox b l.l J f LI x. .t' x- x 44 t ot c -i* -r -Q-: ll 3l; rl. rrbil\ gl tl 225' .#(4)(ui t'. 441 ,\ 145 ;ll ri llt]-- ll tl :] il il lt tl lr ll lr ll 1t il lt Ir 3ll I I x ].],.tr ' i:.ol;,' ' PoS ,#i ,)i.t' ta .Atl ,5 2uLl I N .q 8,EI I r"n(l'€x4kIr-E ta--x- - .4425 x +10*quH ry loL A 5r o 447.7 su 530 c aza 827 575t17 3t? J )x x t. x 444,2 /,x 4.1€.+ I x x 445.7 t-vod e e 1*l e a.a 55{ 233+,. .,r t ' 9* '523 tsloto 6- c x 445.5 I IO6a GI 3+l' 5 E]c o I}-€r (- octol e28e "$ ..4?.*, ..14 It!tnl GI rDtr|nl l:-'i '.4r! 7 5 2 O a236 c oNNN -fi-:i 573 5€5543 ,tao nl ? 4r.6. x c 580 6,22 66054+ t ait o TUt C'5ro c c c .rc6 .rE6 493 o ta,lo :Gl GlI) N| *+e.+ CI 45 47,1 otN c 657 c MATCH 5X.EE 5El../.ti sE.\ I :+ E< i3'7 -._ -., rr!- Ar,.n, t- tl I i t I t Io 222 c c ) SUBSCR I EED A}ID 8EFCIIE ME .IU}IE /Q--eZ /, a4l$H rOI N osr a o (o ao rl\J5 a 6.Z g I oJ ,ito it FE rCK 4, F , TESTER tUGEllE Z00X ilt, UiIDA ilARtE RANX VAICHURA, DoTTtE yAilCHURA, HUS- N F,-a 6 <t I )2/2 FRANX VAI{CHURA AS T0 L0TS 6 t, 7, BL0CK 3,r AND tlltE AS T0 LOTS 8, 9, l0 t/ ll, BL0CK CATTO HEREIN AND THEV OO HEREEY DEDICATE TO sl{oRN T0 7,2, tg76 A.o{/ , uOO ! Ns I I I o120 3 ru oNt- z bvo 7 5bLl I 22. L4 '44 C) SHOIX HEREON FOR SAID PURPOSE RESPECT I VE LY \\ $ e ! $t JT* $ ci tl't !o oa o f .(tcHURA ' I )r.-.-l a^r---r*- I{A Y zt AN IIDY tlA!'{ a L-dr zT 4 &.b r{cHuRA -...._- "g'fi 6tztS'V STfrEE N E9'49'225. 23' 5 89' 49' 23"zz5. oa' r / / ?nn/'. L / AUU tt T'(1 3 6 \$\\ \) \ $ tt (rt (\a \cHtnA 200x, HUS- YAXCHUNA AiD DOTTIEtl^I, HtEEAr{D A}10 IECUTiD TllE FORE- HEIR YOIUXTARY ACT ON OATH, SAY THAT LAXD AS SHOUN ON EO IRON PI PT 6' 00 06, 03,, IAST D TIFE DONAT IOil LAXETTE IIERIDIAN,e-./-z REGISTERED \s I 1 I I I I bo o \9 : l-.\t Ir--o !o \\ \\\\ \Nt_ _29 ,e N 6?" 55', 57" Yt - lOO. b: e 23+r I N cA |'c.- GO.O to2.t9' .P.09 .f,7tbo -@ i;, -frfJi 1-. N 0") I Ir- ! I 6 N o \ \t \ \ (i\ I I I i It./V iN lo /N '' ") n & $ o N to" 29 '7" E t/1 9\ E./x /<t | / /4/),/)/.p ,_/UL,/ 2zt, 7.O'.1 il ,Ll' ,/40/230{ --tt og'5?'97" (r/ * o'42'4 Lc.' y.9* -L,,20 L /Y 89"49'23'// 95.G7 _ _ bb.G }A 9C.oe' 47N 7 I ,,, a eo CHRISTINE K. BAI 7b RD 24. Nota My Commis.ion \ $tr g (05 tri @l ulp{a7 J t20.oo' oq ildS tl o la- 6'P u.€- \) sr to 52e 9 69' Xo' AO' E rO N o 9 29 V,b9. 6 tl o o +5 6'2u.€ l-a, G 9 7'40' gl as GO.o' te N t5" OO' e 6t to 49 L'od el b-- t-. $H :\r tfl i-. ro alov I R.o @' I Io o. Ul \ 5 8?'Yo' 40" E I 23toI ? N lo'4t'e lo9. 04 AXDALL Eln)r1FEeerarrr A I Ee- -- c\ *6 zA.t33.*.,,- /L 22 c/) J f I l//' I I /i' t \\ { -l lv el 'ta*-K&.d.__ )() ,lj U6E 6'a- f- / 2-F3 ne SEPTIC SYSTEM REPAIR v thori za,ttott for'FOR OFFICE USE ONLY i!wiisHIp t7 03 FAIIGE 26.2.LSECTION TA): LOT I--IOUT OF1900 L-r S-'BDIVISIoN/PARTITION (l-f appficable)I,OTIPARC'EL FIiC}.()SED USE OF PROPERTY X r,.esidential [l c<,nrmercial fndustrral Public 2309 N. 5th St., Springfield 97477 I^fCATION ADDRESS ZTPL'I']'Y i-9llafirDrc, STRE ET 5rh Y S fld exit off 105 turn L on N. SFD Septic system repair a DaSCRIPTION Or pnoposeo I",ORK - BE SPECIF tc DECI.ARED S VALUE OIi EI'jPLOYECS l./A}ER SUPPLY NAME AND TELEPHONE NUMBERsiteCLINE, Charles Proposed isting (Bravado Const.,Inc.37123 Wheeler RdBOYDBill ccNTRAcToRIs NAME AND oSR # Bill B TELEPHONE NUMBER746 5554 / {m,*HONE NUMBER al and -in conpliance f-tz-rt DATE f:rther the following INinterest thelegal ofpropergyf]o,n".certi that and aI workfyany shal be INperfomed n1 thetopertaing dework cribed herein and that NO cether rti thatfy tration theth lderBuiregis henoled reon and that subcontractors ildonly THISCHECKED THOROUGHLYAPPLICATION () L];rt' , ,"illr eO I TIAVE CAREFULLY EXAI.TINED THE COMPLETED APPLICATION POR l)) certiiy inforration hereon is true and correct, and that I ra.L pllrchasef of aL'r zed agent. Lane Cowty and the Laws of the State of Oregon f fu!-the pemission of the Buildj.ng Divisj.on 701.055, tha! if exempt the basis for exemptibe used on this project- I HAVE READ AND ACTION 5-12-8B 1 Eeet r:fi e Id B. P. f I pnuurllc,zzoNrNG: tr READ THIS SECTION c L, front_ NO SPECIAL SANITATION: s. I. # inte ()I COM}lENTS AUTHORI ZATION re ar Parti-tion , siMinimum Setbacks 3 COI'01ENAS: Installation Specifications: ING CONDITIONS: parcel Size EN BASED ON THE parcel DaLe tion Record rssued? fl vu" f] u" Le: gta9/V r)Use Maximum Depth of Trenches f,lIf-f- J- LANE COUNTY (Der ORS E PUBLIC WORKS 125 EAST 8TH AVENUE, EUGENE,97401 DATE olvlstoN, 687-4061, SEE REVERSE POR INSPECTION INT'ORMATION cL4-2s R* i,"il:.7"i,-*137fr- ?r, f OE STORIES (i}:''., EXISTING BUILDINGS ON PROPERTY ElHouseEl BarnE GarageEl Mobile. HomeE Shed other - Please. complete all lines inside white boxes, if possible. 9a Q-sr'{z ztP ee PAOPERTY 7 OWNE 3e c TY 7 o v -3."J '12 c -/ z -"/// 9 lr2 fr r+, taEoH^{mcwfr MldhY.ffidtudE*,r. Directlons to slte from Courthouse tla rf /* € O,t/ a9 1/4 S.ction Tar Lot SITE AODRESS (Fcund on trr mrpa ln lh. A.rsm.nl & Trrrfbn D.pf)ZG Z,I MAP, PARCEL NUMBER -t7 03--Tom;EE- -ifis.- --.?i-m- Soction ...-a6.-- Townrhip I own3hrp Rmgc H&nga MAIL PERMIT TO: t/ ztP D ADDRE SS CITY FOR MOBILE HOME PLACEMENT ONLY No. of 1ip-outs - No. oI Bedrms License # Model Year Size Land Managem€nt Div..tatt can not be held responslble for evaluatlon8 or recommendatlonr based on laleo, lnaccurat6 or lncomplete lnlormatlon -i74Te"iffi- -T'AEaiffi-- -tEEr- 7, F ul'* >z'- t?n'_.""en OI,TE I { I t I t RY {4L "t/z{f (I:m,, LA{O MAr^..EMFNr OrVrS@ oao,nh.nr or Pu6r. s.r. CANCELLATION REFUND AUTHORTZATTON PERMIT # TRS/T I V-r ,2,1 TL')8NAME (PLEASE PRI 3 7l 2-3 h)Aoe /orADDRESS neeurcaNr jr4 owNER( ) coNT REASoN poh cRuceLLlNG PERMIT(oR APPLIoATIoN) nrcronft /t b)d, /a 4 SIGNATURE FEES PAID FOR WASTE DISPOSAL SYSTEMS (SITE INSPECTIONS AND/OR APPLICATIONS TO INSTALL THE SEPTIC TANK AND DRAINFIELD) ARE ORDINARILY NONREFUNDABLE. SOME REFUND MAY BE ON BUILDING, PLANNING,ORPLUMBING PORTIONSACCORDINGTOTHE AMOUNT OF THE PERMIT/APPLICOIO* pROCasseo. FEES PAID % REFUND Flood Plain Fee Building Permit Fee Mobile Home Fee Plumbing Permit Fee Mechanical Fee Plan Check Fee State Surcharge Fee _% _% -o/o -"/o _% _% _% Septic Disposal Fee Site lnspection Fee DEQ Surcharge Land Use Application Planning Director Recording Fees Partitions Copies & Ordinances Surveyors Minus $25. for Processing Fee rOTAL AMOUNT TO BE REFUNDED $ $ $ $ $ $ $ $ $ $ $ % % Yo o/o % % SIGNATURE TO DEPARTMENT OF FINANCE: Building Permit Refund State Surcharge Refund Septic Disposal Refund Site lnspection Refund Land Use Application Planning Director Recording Fees Partitions Copies & Ordinances Surveyors TOTAL AMOUNT REFUNDED $ 24 -067 4 I Accl.421 20 I P r o9.020 24 -067 4 I Acct.421 23l Pro9.02 0 24 -0427 I Accl.421 33/ Pro g .24 0 24 -0 427 I Accl.421 34 I P r o 9.24 0 24 -067 4 I Accl.46202l P ro g . 0 20 24 -067 4 I Accl.4 62021 P ro g. 0 1 0 24-1 87 0l Acct.462 1 1 /Prog. 1 1 0 24-067 4l Accl.46202lProg.01 0 24- 1 87 0l Accl.4441 9/Prog. 1 1 0 25-067 4 I Accl.4 4 451/ Pro9.0 1 0 $ $ $ $ $ $ $ $ $ $" Recei Recei Recei Recei Recei Recei Recei Recei Recei Recei pt# pt# pt# pt# pt# pt#_______ t#p t#p PLEASE MAKE CHECK PAYAFLE TO NAME ADDRESS -i7 /J..3 ,'.dhpe lpr fr"}, i'' it*:q,t/ h,:,// Li/( -/ ry,";!, LAND MANAGEMENT DIVISION / Public Works Department I 125 E. 8th Ave., Eugene, OR 97401 (503) 687-4061 o t388-(( db_?{.oo35 ,,'Oa o/o _% _% o d/4 6o