HomeMy WebLinkAboutPermit Building 2005-03-18Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
Building/C ombination Permit
PERMIT NO: COM2005-00261ISSUED: 03/18/2005APPLIED: 03/0412005
EXPIRESz llll9l2005VALUE: $ 20,400.00
SITE ADDRESS: 615 S 34TH ST
ASSESSOR'S PARCEL NO.: 1702313403900
PROJECTDESCRIPTION: Garage
Springfield TYPE OF WORK: Garage
TYPE OF USE: New
Owner:
Address:
JEFF SHERMAN
615 S 34TII ST
SPRINGFIELD OR 97478
Phone Number: 541-
Residential
Phone
s4t-953-2194
Contractor Type
General
Electrical
Contractor
ALPINE CONSTRUCTION
OWNER
Expiration Date
04t02t2005
CONTRACTOR INFORMATI(
)RMATION
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
Frontyard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Street Improvements:
Storm Sewer Available:
Special Instruction:
30.00
8.00
71.00
Partially Improved
Yes
U
VN
# of Stories:
Height of Structure
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
%o oflot Coverage:
ON: Orego n law reqr
adoPted bY the O
nter. Those rules
-0010 throu
obtain cuPies
Geder is 1
Lot Size:
Notitication
816
Yes
REQUIRED PARKING
Total: 2
Handicapped:
Compact:
Notes: Dryrveu required - soil type 76 good ror drywer$ttflffillffi til[fl,,[&t10,,fi5.$Ul]" C0turN,1ENCED 0R lS ABAND0NED F
ANY 1BO DAY PERIOD.
Sidewalk Type:
l,ii:l tL"E: Downspouts/Drains: Dryrvell-Provide
TiiiS PLHI,iiT SHALL EXPIRE IF THE WOBKDTWEIIENgiNCCTiNg
IS NOT
OR
PUBLIC IMPROVEMENTS
Pase I of3
*:
License
125864
ol
Status Issued
225 Fifth Street, Springfield, OR
S4l-72G3753 Phone
541-726-3676Fax
541-7 2G37 69 Inspection Line
Building/Combination Permit
PERMIT NO: COM2005-00261ISSUED: 03/18/2005APPLIED: 03/0412005
EXPIRESz llll9l2005VALUE: $ 20,400.00
Description
Garage
Tvpe of Construction
Garage
$ Per Sq Ft Square Footage
or multiplier or Bid Amount
$25.00 816.00
Total Value of Project
Amount Paid Date Paid
Value
$20,400.00
$20,400.00
Date Calculated
03t04t2005
Fee Description
Plan Review Residential
+ l0oh Administrative Fee
+ 7oh Sttte Surcharge
Garage/Carport
Minimum/Adj ustment Plumbing
Plan Review Minor - Planning
SDC Sanitary/Storm Admin
Storm Drainage Impervious Area
+ l0%o Administrative Fee
+ 7o/o State Surcharge
Add, Alter, Extend Circ Ea Add
Perm Serv/Fdr 200 amps or less
Total Amount Paid
$12s.58
$23.82
$16.67
$193.20
$4s.00
$s9.00
$14.13
$282.52
$7.80
$5.46
$1s.00
$63.00
$851.18
3t4t0s
3/18/05
3/18/05
3/18/05
3/18/05
3/18/05
3/18/0s
3/r8/05
5n9t05
5n9t05
5n9t05
5n9t05
Receipt Number
1200s0000000000029s
2200s000000000003r1
2200s00000000000311
2200s00000000000311
220050000000000031 I
2200500000000000311
220050000000000031 1
2200500000000000311
1200s00000000000639
1200500000000000639
1200500000000000639
1200s00000000000639
Fees Paid
Plan Reviews
Initial Review
Planning Review
Public Works Review
Structural Review
Structural Review
03/08/2005
03/08/200s
03/08/2005
03/08/200s
03nu200s
03/08/200s
03n6t2005
03/r0/2005
03/1U2005
03114t2005
APP
APP
APP
IO
APP
SKG
TAJ
CAS
LLH
JB
This property includes 2 tax lots, but
it is only one building lot. The
property line was adjusted through
PLAJO# 1999-10-0270.
Storm drainage to existing system
3/10/2005 CAS
Plans forwarded to Jason Bush for
Review
To Request an inspection call the 24 hour recording at 726-3769. All inspection 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.
Reouired fnsnecfions
Footing: After trenches are excavated.
Paee 2 of 3
Valuation Description I
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
Building/Combination Permit
PERMIT NO: COM2005-00261ISSUED: 03/18/2005APPLIED: 03/0412005
EXPIRESz llll9l2005VALUE: $ 20,400.00
Foundation: After forms are erected but prior to concrete placement.
Shear Wall Nailing: Before covering sheathing with finish materials.
Framing Inspection: Prior to cover and after all rough in inspections have been approved.
Final Building: After all required inspections have been requested and approved and the building is complete.
Storm Sewer Line: Prior to lilling trench.
Rough Electric: Prior to Cover
Electric Service: Approval required prior to utility company energizing service.
Final Electric: When all electrical work is complete.
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 further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springlield 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 Community Services Division, Building Safety.
I further certify that only contractors and employees who are in compliance with ORS 70f .005 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 is located at the front of the property, and the approved set of plans will remain on the site at all
times during construction.
Owner or Contractors Signature Date
Page 3 of3
T
225 Fifth Street
Springfield, Oregon 97 477
541-726-3759 Phone
^ity of Springfield Official Receipt
--.levelopment Services Department
Public Works Department
RECEIPT #: 1200500000000000639 Date: 05/19/2005 8:57:14AM
Job/Journal Number
coM2005-00261
coM2005-00261
coM2005-00261
coM2005-00261
Description
+ 7Yo State Surcharge
+ ljYo Administrative Fee
Perm Serv/Fdr 200 amps or less
Add, Alter, Extend Circ Ea Add
Amount Due
5.46
7.80
63.00
15.00
Item Total:$91.26
Payments:' Type ofPayment Paid By
CheckNumber Autlrorization
Received By Batch Number Number How Received Amount Paid
I
\..
I
CreditCard
I
JEFF SHERMAN djb 082617 In Person $91.26
Payment Total:
-SIIF
i
slt9l200s Page I of I
225 FIFTH STREET . SPRINGFIELD, OR97477 o PH:(541
E LE CTP.I CAL P ERMIT AP P LI CATI ON
City Job Number A?J,og- ooz6l Date
)726-3753 o FAX: (541)726-3689
%
3.
B.
0090
E.
Service Included
1000 sq. ft. or less
Each additional500 sq. ft. or
portion thereof
Each Manufact'd Home or
Modular Dwelling Service or
Feeder
One Circuit
Each Additional Circuit or with
Service or Feeder Permit
Pump or irrigation
Sigr/Outline Lighting
by
oAR q52-001.
ol the rules bv
@e the telePhone
rc9qr{seF6ldtr UtiiitY Notification
-800€32-2344
,
eo
t9
.00
$ 63.00
$ 75.00
$12s.00
$163.00
$375.00
$ s0.00
$ 43.00
$ 3.00
$ s0.00
$ 50.00
LEGAL DESCRIPTION
l-?o23, j Y 03 ?oo
JOB DESCRIPTION
9r^g ?*'r, I Q-1 rf,-ut t h
Permits are non-transferable and expire if work is
i' not started within 180 days of issuance or if work is
Suspended for 180 days.
2.
Electrical Contractor
Address
Phone
Supervisor License Number
Expiration Date
Constr. Contr,
Expiration
Supervising Electrician
Owners Name
Address 6 t
a4( 5 h<
City r Phone lE 8-1.2 z-ct
OWNERINSTALLATION
The installation is being made on properfy I own which
is not intended for sale, lease or rent.
C. Temporary Services or Feetlers
Installation, Alteration or Relocation
200 Amps or less $ 50.00
201 Amps to 400 Amps $ 69.00
401 Amps to 600 Amps $100.00
Over 600 or 1000 Volts see "B"
D.
New Alteration or Extension Per Panel
A.
63
h
City
5
l\tliscellaneous (Service/feeder not inclutled) -Ea ch lns talla tiotr
c
Limited Energy/Residential $ 25.00
Limited Energy/Commercial $ 45.00
Minimum Electric Permit Inspection Fee is $45.00 * Surcharges
7b
,,lb7%o State Surcharge
l0% Administrative Fee
TOTAL
700
?t ?e
Inspection Request: 726-3769
Shared Drive(T:/Building Forms/Electrical Permit Appl ication I {3.doc
1. LOCATION OF6r; s
rul€s
drvelling unit.
or Relocation:c o r{TRAcT o R r N STALLATI I N O N LY
:
'-/s
FIELD
Building/Combination Permit
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
PERMIT NO: COM2005-00261ISSUED: 03/18/2005APPLIED: 03/0412005EXPIRES: 09/1812005VALUE: $ 20,400.00
SITE ADDRESS: 615 S 34TH ST
ASSESSOR'S PARCEL NO.: 1702313403900
PROJECTDESCRIPTION: Garage
Springfield TYPE OF WORK Garage
TYPE OF USE: New
Owner:
Address:
Contractor Type
General
JEFF SHERMAN
615 S 34TH ST
SPRINGFIELD OR 97478
Contractor
ALPINE CONSTRUCTION
License
12s864
Expiration Date
04t02t200s
PhoneNumber: 541-
Residential
Phone
541-9s3-2194
CONTRACTOR INFORMATION
m
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
Frontyard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
# of Stories:
Height of Structure
Type of Heat:
Water Type:
Range Type:
Energy Path:
Sprinkled Building:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
Yo ofLot Coverage:
Lot Size:
Sq Ft lst Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
U
YN
816
nla
30.00
8.00
71.00
Yes
Sidewalk Type:
Downspouts/Drains:
REQUIRED PARKING
Total: 2
Handicapped:
Compact:
Drywell - Provide
Drywell Engineering
xot0090'
Center is 1-800 -392'2344\
type 76 good for drywell Standard PIan included 3/10/2005 CAS
ication
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
DEVELOPMENT INFORMATION
Description Type of Construction
Page 1 of3
Date Calculated
c
F]Rr
AiVDO
rHi0
Valuation Description I
Value
Building/Combination Permit
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
PERMIT NO: COM2005-00261ISSUED: 03/18/2005APPLIED: 03/04/2005
EXPIRES: 09/1812005VALUE: $ 20,400.00
Garage Garage
Fee Description
Plan Review Residential
+ l0Yo Administrative Fee
+ 77o State Surcharge
Garage/Carport
Minimum/Adjustment Plumbing
PIan Review Minor - Planning
SDC Sanitary/Storm Admin
Storm Drainage Impervious Area
Total Amount Paid
$25.00 816.00
Total Value of Project
Date Paid
3t4t05
3/18/0s
3/18/05
3/18/05
3/18/05
3/18/0s
3i18105
3/18/05
$20,400.00
$20,400.00
Receipt Number
1200s0000000000029s
2200s00000000000311
2200500000000000311
2200500000000000311
2200500000000000311
2200500000000000311
2200500000000000311
2200s00000000000311
03t04t200s
Amount Paid
$12s.s8
$23.82
$16.67
$193.20
$4s.00
$s9.00
$14.13
$282.52
$759.92
F ees Paid
Plan Reviews
Initial Review
Planning Review
Public Works Review
Structural Review
Structural Review
03/08/2005
03/08/200s
03/08/2005
03/08/200s
03mt2005
03/08/200s
03fi6t2005
03/10/2005
03/ru200s
03n412005
APP
APP
APP
IO
APP
SKG
TAJ
CAS
LLH
JB
This property includes 2 tax lots, but
it is only one building lot. The
property line was adjusted through
PLA JO# 1999-10-0270.
Storm drainage to existing system
3/10/2005 CAS
Plans forwarded to Jason Bush for
Review
To Request an inspection call the24 hour recording at 726-3769. All inspection 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.
Footing: After trenches are excavated.
Foundation: After forms are erected but prior to concrete placement.
Shear Wall Nailing: Before covering sheathing with linish materials.
Framing Inspection: Prior to cover and after all rough in inspections have been approved.
Final Building: After all required inspections have been requested and approved and the building is complete.
Storm Sewer Line: Prior to lilling trench.
Pase 2 of3
Keoutred Insnectrons I
Building/Combination Permit
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
PERMIT NO: COM2005-00261ISSUED: 03/18/2005APPLIED: 03/0412005
EXPIRES: 09/1812005VALUE: $ 20,400.00
I
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 further 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 OCCUP made of any structure without permission of the Community Services Division, Building Safety.
I further who are in compliance with ORS 70f .005 will be used on this project.
, are requested at the proper time, that each address is readable from theto
that the front of the property, and the approved set of plans will remain on the site at all
or Date
Page 3 of3
JOLIRNAL OR JOB NUMBER:
NAME OR COMPANY:
LOCATION:
TAX LOTNUMBER:
DEVELOPMENT TYPE:
NEW DWELLING I.INITS
I. STORM DRAINAGE
DIRECT RUNOFF TO CITY STORM SYSTEM
CITY OF SPRINGFIELD SYSTEMS DEVELOPMEN] CVORKSHEET
coM2005-00261
Jeff Sherman
615 S 34th St
t702313403900
SINGLE FAMILY
0 BUTLDING SrZE (SF. 816 LOT SIZE (SF):0
f rMPERVroLis sr. \
J qrr.:o
COST PER S.F
s0.310
COST PER DFU
s24.04
$ l 8.28
NUMBER OF LTNITS
0
NUMBER OF LINITS
0
ADM. FEE RATE
5%
CHARGE
$282.52
UCTED TO CITY STANDARDS
DISCOUNTRATE
50%
$282.52
DISCOUNT
$0.00
RLINOFF ROUTED TO DRYWELL DESIGNED AND
IMPERVIOUS S.F
0.00
ITEM 1 TOTAL - STORM DRAINAGE SDC
2. SANITARY SEWER - CIry
A. REIMBURSEMENT COST:
x
ITEM 2 TOTAL - CITY SANITARY SEWERSDC
3. TRANSPORTATION
A. REIMBURSEMENT COST:
NUMBER OF DFU'S
0
B. IMPROVEMENT COST:
NUMBER OF DFU's
0
ADT TRIP RATE
9.57
B. IMPROVEMENT COST:
ADT TRIP RATE
9.57
SUBTOTAL
s282.52
x
x
x
x
x
x
$0.00
COST PER TRIP
$ I 8.30
COST PER TRIP
s80.72
$0.00
NEW TRIP FACTOR
1.00
NEW TRIP FACTOR
1.00
xx
xx
ITEM 3 TOTAL. TRANSPORTATION SDC
4. SANITARY SEWER - MWMC
A. REIMBURSEMENT COST:
NUMBER OF FEU's
0
B. IMPROVEMENT COST:
NUMBER OF FEU's
0
MWMC CREDIT IF APPLICABLE (SEE REVERSE)
MWMC ADMINISTRATIVE FEE
ITEM 4 TOTAL - MWMC SANITARY SEWER SDC
SUBTOTAL (ADD ITEMS I,2,3, & 4)
x
$0.00
s282.52
CHARGE
sr4.l3
TOTAL SANITARY ADMINISTRATION FEE:
TOTAL TRANSPORTATION ADMINISTRATION FEE:
Cheryl Slaymaker 3n8t200s
COST PER S.F
$0.310
COST PER FEU
$82.03
$0.00
$0.00
$0.00
$0.00
$0.00
$296.6s
1070
109 r
1092
l 093
1094
I 054
1055
1 054
1 056
a
rrl
IJo(,
&r!Fa
trl
COST PER FEU
s865.3 1
PREPARED BY DATE
TOTAL SDC CHARGES
DRAINAGE FIXTURE UNIT CALCULATION TABLE
NUMBER OF NEW FXTURES X UNIT EQUTVALENT : DRAINAGE FIXTURE UNITS
FOR CALCULATE ONLY THE NET ADDITIONAL
NO. OF FIXTURES
UNIT
FIXTURE ryPE NEW OLD ALENT
MISCELLANEOUS DFU ryPE NUMBER OF EDU'S
TOTAL DRAINAGE FIXTURE UNITS
rsa toa unit set at I 67
MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE
20
DRAINAGE
FIXTURE
UNITS
0
2
t979
tEDU
BEFORE 1979
1979
1980
1982
1984
I 985
1986
1987
1988
t989
1990
l99l
1992
t993
t994
1995
t996
1997
1998
1999
$5.29
$5.1 I
$5.12
$4.98
$4.80
$4.63
$4.40
$4.07
$3.67
$3.22
$2.73
$2.25
$1.80
IS LAND ELGIBLE FOR ANNEXATION CREDIT?
(Enter I for Yes, 2 for No)
IS IMPROVEMENT ELGIBLE FOR ANNEX. CREDIT?
(Enter I for Yes, 2 for No)
BASE YEAR
CREDIT FOR LAND (IF APPLICABLE)
2
l98l
1983
VALUE / lOOO
$0.00
CREDIT RATE
s5.29x
CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION)
VALUE / IOOO CREDIT RATE
$0.00 x $5.29
TOTAL MWMC CREDIT$1.59
$1.45
$1.25
$t.os
$0.92
$0.72
$0.48
$0.28
$o.og
$0.05
0 0 3 0BATHTUB
00n1DRINKING FOUNTAIN
0 3 00FLOOR DRAIN
0003INTERCEPTORS FOR GREASE / OIL / SOLIDS / ETC.
6 000INTERCEPTORS FOR SAND / AUTO WASH / ETC.
0 2 00LALTNDRY TUB
0030CLOTHESWASHER / MOP SINK
6 000CLoTHESWASHER - 3 OR MORE (EA)
0 12 00MOBILE HOME PARK TRAP (I PER TRAILER)
0001RECEPTOR FOR REFRIG / WATER STATION / ETC.
3 000RECEPTOR FOR COM. SINK / DISHWASHER / ETC.
0 2 00SHOWER, SINGLE STALL
0002SHOWER, GANG (NUMBER OF HEADS)
0003SINK: COMMERCIAL/RESIDENTIAL KITCHEN
2 000SINK: COMMERCIAL BAR
0 2 00SINK: WASH BASIN/DOUBLE LAVATORY
0001SINK: SINGLE LAVATORY/RESIDENTIAL BAR
5 000URINAL, STALL / WALL
0 0 6 0TOILET, PUBLIC INSTALLATION
0003TOILET, PRIVATE INSTALLATION
0
YEAR
ANNEXED
CREDIT RATE/S1,OOO
ASSESSED VALUE
$0.00
2000
El
2001
225 Fifth Street
Springfield, Oregon 97 477
541-726-3759 Phone
^ity of Springfield Official Receipt
;velopment Services Department
Public Works Department
RECEIPT#: 2200500000000000311 Date:03/18/2005 12:04:41PM
Job/Journal Number
coM200s-00261
coM2005-00261
coM2005-00261
coM200s-00261
coM2005-00261
coM2005-00261
coM2005-00261
Description
Storm Drainage Impervious Area
SDC Sanitary/Storm Admin
Garage/Carport
Minimum/Adjustment Plumbing
+ 7oh State Surcharge
+ l0% Administrative Fee
Plan Review Minor - Planning
Amount Due
282.52
14.13
193.20
45.00
t6.67
23.82
s9.00
Item Total:$634.34
Payments:
Type of Payment Paid By
Check Number
Received By Batch Number
Authorization
Number How Received Amount Paid
Check ALPINE CONSTRUCTION lkw 1722 In Person
Payment Total:
$634.34
-sfi:ri-
Li
3tr8/200s Page I of I
atafalaD
f/
)
79fi!e8,e9
Barqain and Sale Deed
KNOH ALL MEN BY THESE PRESENTS, That Gary Budd
Grantor ,
Gran teela
grantee, g
i ts succes
i taments a
ed and des
i n cons i derati on of the acceptit
nd the use or holdinQ of sajd nrrantor hereby qrants, bareajns,
sors and ass'igns, al I the fol I olv
nd appurtenances, situated in th
cribed as follorvs:
of Sprinqfield, 0reqon,
ent or future public use byys unto the sai d orantee,ty, with the tenements, hered-
e attd State of 0psge6, bound-
rr ce by the C'i ty
ooerty for pres
sclls and conve,'ine real prpper
e Count.y of Lan
Commencing at the Northrvest co1'neI of ltlock 12, DOLJCL;\S (iARl)llNS,
?s platted and rccorded in Voltrmc 73, page 4, Lane cotrnt). or"go,i
!1at Records , Lane county, oregorr r saicl po int being rnarkerl b),' ,,P,K. nail; tltence along the centerlinc of South 54Ih Street Sotrth0o 13' 20" lVest 372,2.1 [cct to the Northrvest corner of l,ot 7 insaid Block l2; thcncc Sorrth B9o 43'Iiast 20.0 fcet to the foint oBeginnirg; thencc south 89 " 4.i' lia.st 5 . 00 f cct ; thence south (ro IWest 34.86 feet; thcnco alcrng a 46.00 foot rarlirrs cut'vo to thc. rja distance of 94.26 Fcct Ithc choi-cl ol' rvhich bcurs Sorrth Io 5()' .tl{est 78.61. J,ect) to iI Pojnt on tlrc. North Iitrc ol'the Sor-rtlrc:r'nPacific Railroad right-ol'-wa1,; tlrencc Nolth {14" l9' [\rest 2.79 Fcot;thence North 0o l3' zLl" Ilast I13.13 foet to tlic Point ot Bcginning.
Ihe same hereby and forever dedjcated to the rrubljc to be used as public road.
T0 HAVE AND T0 H0LD, the above described and qranted premises unto the said qrantee,
its successors and assiqns forever
The rnonetar.y cons'ideration for this conveyance is
In addition the Grantors hereby clrant, barclajn, sell and conve.y unto the Grantee, a
perpetual easement S.00 feet in wjdth, toeether with the right to go upon said
easement area hereinafter descrjbed for the purpose of construct'ing, reconstructing,
majntaininq and using public uti'litjes which may hereafter be installed on the
fol low'inq described property, to-wit:
f
J
gl
0'
:0"
t
-0-
A 5.00 foot
East margin
strip o f land alorte the East side attcl abutting thc
of the ahove conveyancc.
the Grantors bove named have hereunto set their hands and seals
?0.r,8,2,1 (r {llt.}(J).,FI t
T0 HAVE AND T0 H0LD the above easement to the said Grantee, its successors and assiqns
fo re ve r,
IN I^IITNESS I.JHEREOF,this ' / Z- day of ,1977..
-
STAIE OF OREGON
( srAL )
(srAL )
that on this /Z day of
ry Publ i c an r sa'i County an
ESCT e nan o execute ew
ls ZZ, befo
tate, personal 1y aPpeared
known to me to be
n instrument and
SS
County orfu
BE IT REMEMBIRED,
undersigned, a ['lo
wi thi n named
i dent'i ca I i n
the
the
ua t
acknovrledged to me that he- executed the same f reel.y and vol untarily
IN TESTIMQNY |^JHEREOF, I have hereunto set my hand and affixed my official seal the dav
and year Iast above written.
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