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Home My WebLink AboutPermit Building 1993-10-10S,)GFIELE RESIDENTIAL PERMIT APPLICATION lnspections: 726'3769 Office: 726'3759 LOCATION OF PROPOSED WORK ZoS ASSESSORS MAP: h, JOB NUMBER 225 Fif th Street Springfield, Oregon 97 477 TAX LOT:6*A SUBDIVISION & LOT: -- BLOCK PHONE ztPSTATE: OWNER: CITY: NEW ---- REMODEL _-. ADDITION DEMOLISH OTHER DESCRIBE WORK: MECHANICAL: --- ELECTRICAL: -- PHONEEXPI RESADDRESS t) /9 V-/i ) CONTRACTOR'S NAME CONST. CONTRACTOR # G EN EFIAL: PLUMBING _ OFFICE USE _ LAND USE g OF BDRMS: RANGE: FLOOD PLAIN WATER HEATER: r OF UNITS: SECONDARY HEAT: SOUARE FOOTAGE: OUAD AREA: I OF BLDGS:ZONING CODE: OCCY GROUP: * OF STORIES: CONSTR. TYPE: HEAT SOURCE: To request an inspection, you rnust call 726-3769. This is a24hour recording. All inspections recluested before 7:00 a.m. will be made the same working day, lnspections requested after 7:00 a.m. will be made the following work day. REOUIRED INSPECTIONS Temporary Eleclric Site lnspeclion - To be made after c'xcavation, but Prior to setting forms. Underslab Plumbing/ Electrical / Mechanical - Prior to cover. Footing - After trenches are excavated. Masonry - Steel location, bond beams, grouting. Foundation - After forms are erectecl but Prior to concrete placement. Underground Plumbing - Prior to filling trench. Underlloor Plumbing / Mechanical - Pnor to insulation or decking' Post and Beam - Prior to floor insulation or decking. Floor lnsulation - Prior to decki ng. Sanitary Sewer - Prior to filling trenclt. Storm Sewer - Prior to filling trench. Water Line - Prior to filling trench. Rough Plumbing - Prior to cover. )Vf Rouoh Mechanical - Prior to4l cove"r f/f,qouoh Electrical - Prior to /r- cover. Final Plumbing - When all plumbing work is complete. Final Eleclrical - When all etectrical work is complete. ,x., E N-rf walllceilino lnsulalion - Prior to [A "oror. p. ",*ull - Prior to taning' Electrical Service - Must be approved to obtain Perrnanent electrical power. Fireplace - Prior to facing materials and framing lnsP- ming - Prior to <;over. Wood Stove - After installation lnsert - After firePlace aPProval and installation of unit. Curbcut & APProach - Af ter forms are erected but Prior to placement of concrete. Sidewalk & DrivewaY - After excavation is comPlete, fortns and sub-base materi.rl in Place. Fence - When comPleted Streel Trees - When all.required trees are Planted. f,TFinal Mechanical - When all )Ane"t unical work is complete. ']Vl finat Buildins - When all Aequired inspections have been ' approved and building is com pleted. Other MOBILE HOME INSPE TIONS Blocking and Set:Up - When all blocking is comPlete. Plumbing Connections - When home has been connected to water and sewer. Electrical Conneclion - When blocki ng, set-up, and Plumbing inspections have been apProved and the home is connected to the service panel. Final - After all required inspections are approved and porches, skirting, decks, and venting have been installed.w 7-/:ADDRESS: tl tl tf tl tl E tl tl r fl r tl ff Lot faces Lot sq. ftg. Lot coverage Topography Total height Lot Type - lnterior - Corner - Panhandle - Cul-de-sac Setbacks P.L.HSE GAR N .) ACC E IS THE PROPOSED WORK IN THE HISTORICAL DISTFIICT, OR ON THE HISTORICAL FIEGISTER? - lf yes, this application must be signed and approved by the Historical Coordinator prior to permit issuance. APPBOVED: BUILDING VALUE, PLAN CHECK AND BUILDING PERMIT This perrnit is granted on the express condition that the said conslruction shall, in all respects, conform to the Ordinance adopted by the City of Springfield, including the Developmerrt 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. Pla DateCVcwed By 3A Date PaicI Receipt Number: , Received B Plan Check Fee 181a - VALUE (A) X $/SQ. FT. Total Value Building Permit Fee State Surcharge Total Fee /*d.O/ 7,10 ,99 BUILDING PERMIT ITEM SQ. FT, Main Garage Carport Systerns Dcveloprnent Charge is due on all undeveloped properties within the City limits which are being improved. SYSTEMS DEVELOPMENT CHARGE (SDC) (B)NA ADDITIONAL COMMENTS ITEM Fixtures Residential Bath(s) Sanitary Sewer Water Storm Sewer Mobile Home FEE NO FT. FT. Fi. (()) 4a,* PLUMBING PERMIT Plumbing Permit State Surcharge Total Charge Wood Stove/ lnsert/ Fi replace Unit Dryer Vent 4ro _ar__ ,/5ao2//() 1<2I(D) 7{ Vent Fan a€Mechanical Permit lssuance State Surcharge Total Permit MECHANICAL PERMIT Fu rnace Exhaust Hood No/ By signature, I statc and agree, that I have caref ully examined the completed application and do hereby certify that all information hereon is true and correct, ancl I f urther certify that any and all worl< performed shall be done in accordance with the Ordinances of the City of Springfield, and the Laws of the Statc 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 furtlrer certify that only contractors and employees who are in compliance with ORS 701.055 will be used on this p rolec t. I f urther agree to ensure that all required inspections are requested at the proper time, that each address is readable from tl.re street, that the permit card is located at the front of the property, and the approved set of plans will remain natu Date d son the sit ructionall ti MISCELLANEOUS PERMITS Mobile Home State lssuance State Surcharge Sidewalk - ft Curbcut - ft Demolition State Surcharge Total Miscellaneous Perrnits ,//@ rhrrr*' (E) ,u 3e f,/DATE PAID AMOUNT RECEIVED FIECEIVED BY - VALIDATION: RECEIPT NUMBER TOTAL AMOUNT DUE (excluding electrical) (A, B, C, D, and E Combined) €zEl I -=; 4z!- n,lo,/ts /os3e RONALD L. RICHARDSON 305 North 38th st. Springfield Ore. 97478 Job Number 930014 To: Springfield Building permit person I have not finished or ha date. I need an extension a problem with this house has you could exLend the permit d a inspection at the above address t,o this t this time. My main Employment, and further kept me from finishing the permit. So, if I am sure I could finish the house on time. Thank You ftR- r\*:'-scu^:r-e- pndc\noAD GS \\,n oeNears q3\WE(J E A[i\d \\$e, \ffle \o \rd \ SP,lI]{GF RESIDENTIAL PERMIT APPLICATION lnspections: 726-3769 Office: 726-3759 JOB NUMBER 225 Fifth Street Springfield, Oregon 97 477 LOCATION OF PROPOSED WORK:Sos N SZprt ASSESSORS MAP:lToZ Dr / i TAX LOT:L goc) LOT:BLOCK:SUBDIVISION PHONE: L.,*.4J,0>47XZIP:STATv --TCITY: ADDRESS: OWNER: 30S N ts 3(/" DESCRIBE WOBK: NEW - REMODEL ADDITION DEMOLISH OTHEB - MECHANICAL: - ADDRESS EXPIRES PHONECONTRACTOR'S NAME ELECTRICAL: CONST. CONTRACTOR # GENERAL: PLUMBING _ OFFICE USE _ g OF BDRMS: RANGE:WATER HEATER: ZONING CODE: FLOOD PLAINLAND USE: # OF UNITS QUAD AREA: r OF BLDGS: SECONDAFIY HEAT: SQUARE FOOTAGE: CONSTFI. TYPE: HEAT SOURCE: OCCY GROUP: * OF STORIES: To request an inspection, you must call 726-3769. This is a24hour iecording. All inspections requested before 7:00 a.m. will be made the same vrorking day, lnspections requested after 7:0o a.m. will be made the following work day. REOUIRED INSPECTIONS Rough Mechanlcal - Prior to cover. pf ri,',al ptumbins - When ail ,/a{-pJumbing work is complete. Site lnspection - To be made after excavation, but prior to setting forms. Rough Electrical - Prior to Final Electrical - When alt electrlcal work is complete.cover Underslab Plumbing/ Electrical / Mechanical - Prior to cover. Electrical Service - Must be approved to obtain permanent electrical power. Final Mechanical - When atl mechanical work is complete. Footing - After trenches are excavated.Fireplace - Prior to facin-c; materlals anrl framing lnsp. Final Building - When all required lnspections have been approved and building is completed.Masonry - Steel location, bond beams, grouting. l-_l Framing - Prior to cover. Foundatlon - After forms are erected but prior to concrete placement. Other WalllCeiling lnsulatlon - Prlor to cover. Underground Plumbing - Prior to filling trench.[-l Drywall - Prior to taping. MOBILE HOME INSPE TIONSUnderlloor Plumblng / Mechanical - Prior to insulation or decking.Wood Stove - After installation Posl and Beam - Prior to floor insulation or decking.lnsert - After fireplace approvql and lnstallation of unit. Blocking and Set.Up - When ail blocking is complete. Floor lnsulalion - Prior to decking.Curbcut & Approach - After forms are erected but prior to placement of concrete. Plumbing Connections - When home has been connected to water and sewer. Sanitary Sewer - Prior to filling trench.Electrical Connection - When blocking, set-up, and plumbing inspections have been approved and the home is connected to the service panel. Slorrn Sewer - Prior to filling trench. Sidewalk & Driveway - After excavation is complete, forms and sub-base material in place. Water Line - Prlor to filling trench.[--l Fence - When completed Street 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 f i. |: 7o*^18 L TiJorAsoa [-l Temporary Etectric E tl E E tl tl E E E tl E tl tl t:] tl tl E E Lot faces Lot sq. ftg. Lot coverage Topography Total height Lot Type - lnterior - Corner - Panhandle - Cul-de-sac. Setbacks P.L.HSE GAR ACC N S W E i i THE PROPOSED WORK lN THE HISTORICAL DISTRICI OR ON THE HISTORICAL REGISTEFI? - lf yes, this application must be signed and approved by the Historical Coordinator prior to permit issuance. APPROVED: 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 ot buildings, and may be suspended or revoked at any time upon violation of any provisions of said ordinances. Plans Reviewed By Date Plan Check Fee: Date Paid: Fleceipt Num Received 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.Z Zc^9 (o) N0 FT. FT. FT. ao 0o PLUMBING PERMIT Plumbing Permit State Surcharge Total Charge ADDITIONAL COMMENTS Wood Stove/ lnsert/ Fireplace Unit Dryer Vent (D) N0Vent Fan Mechanical Permit lssuance State Surcharge Total Permit MECHANICAL PERMIT Fu rnace Exhaust Hood 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 f urther certily 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 contractors and employees who are in compliance with ORS 701.055 will be used on this proiect. 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. $rsn^tu,. &^.tt ) PrA 4 Date e D"a- 73 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, Q and E Combined) a- /,oo f 2 /. o-o DATE PAID AMOUNT RECEIVED RECEIVED BY VALIDATION: RECEIPT NUMBER 4_ RESIDENTIAL PERMIT APPLICATION lnspections: 726-3769 Office: 726-3759 JOB NUMBER 225 Fifth Street Springfield, Oregon 97 477 ASSESSORS MAP: LOT BLOCK: TAX LOT: ZIP: fl STATE: PHONE:74 /- /?a O.CITY: ADDRESS: OWNER: NEW - FIEMODEL AODITION DEMOLISH OTHER - DESCRIBE WORK: d-\d L EXPIRES PHONE h 3gazo 3c) L tt tt CONTBACTOR'S NAME MECHANICAL: ELECTRICAL: CONST. CON'I-RACTOR # GENERAL: PLUMBING RANGE: _ OFFICE USE - LAND USE: WATER HEATER: ZONING CODE: FLOOD PLAIN * OF UNITS: OUAD AREA: * OF BLDGS: SECONDARY HEAT SOUARE FOOTAGE: OCCY GROUP: r OF STORIES: CONSTR. TYPE: HEAT SOURCE: To request an inspectlon, you must call 726-3769. Tlrls is a 24 hour recording. All inspections requested before 7:00 a.m. will be made the same worklng day, lnspections requestecl after 7:OO a.m. will be made the following work day. REQUIRED INSPECTIONS [l Temporary Electric Rough Mechanical - Prior to cover. Final Plumbing - When allplumbing work is complete. Site lnspection - To be made after excavation, but prior to setting forms. Underslab Plumbing/ Electrical / Mechanical - Prlor to cover. Fooling - After trenches are excavated. Masonry - Steel location, bond beams, grouting. Foundation - After forms are erected but prior to concrete placement. Underground Plumbing - Prior to filling trench. Underlloor Plumbing / Mechanical - Prior to insulation or decking. Post and Beam - Prior to lloor insulation or decl<ing. Floor lnsulation - Prior to decking. Sanitary Sewer - Prior to filling trencl'r. Slorm Sewer - Prior to filling trench. Water Line - Prlor to filling trench. Rough Plumbing - Prior to cover. K*'I"?: Erecrricar - prior to x5[:1,,:,"TlJf,?,,;"H;[il1 ffiftectrical Service - Must be ,Happroved to obtain permanent electrical power. Final Mechanical - When all mechanical work is complete. N4 Framing - Prlor to cover..A X Fireplace - Prior to faclng materlals and framing lnsp. lation - Prior to f{ finat Buildins - When alt fr.qequired inspections have been approved and building is completed. El-otY*ull - Prior to taping' Wood Stove - After installation lnsert - A(ter flreplace approvEl and installation of unit. Curbcut & Approach - After forrns are erectecl but prior to placement of concrete. Sidewalk & Driveway - After excavation is complete, forms and sub-base material in place. Fence - When completed. Street Trees - When all required trees are planted. Other MOBILE HOME INSPE TIONS Blocking and Set.Up - When ail blocking is complete. Plumbing Conneclions - When home has been connected to water and sewer. Eleclrical Conneclion - When blocking, set-up, and plumbing inspections have been approved and the home is connected to the service panel. Final - After all required inspections are approved andporches, skirtlng, decks, and venting have been installed. LOCATION OF PROPOSED WOBK:/7oz s/ ls /--ffi SUBDIVISION: 7>q/? L*,-l) l-Pi .-,ko t )L-+, ADDFIESS # OF BDRMS; _ E r E E E tl tl tl E E tl .\ Lot faces Lot sq. ftg. Lot coverage Topography Total height Lot Type - lnterior - Corner - Panhandle - Cul-de-sac. Setbacks P,L.HSE GAR ACC N S E IS THE PROPOSED WORK IN THE HISTORICAL DISTRICT, OB ON THE HISTOFIICAL REGISTER? - lf yes, this application must be signed and approved by the Historical Coordinator prior to permit issuance. APPFIOVED: VALUE L?s (A) X $/SQ. FT, Total Value Building Permit Fee State Surcharge Total Fee 2k1D,@ 39,sa 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. - <-, o3 Plans By //r, =/ late Fleceipt Numbe Plan Check Fee: Date Paid Flecei ved SYSTEMS DEVELOPMENT CHARGE (SDC) (B) N, T Systems Development Charge is due on all undeveloped properties within the City limits which are being improved. ITEM Fixtu res Residential Bath(s) Sanitary Sewer Water Storm Sewer Mobile Home FEE (c) FT. PLUMBING PERMIT No Plumbing Permit State Surcharge Total Charge ADDITIONAL COMMENTS Wood Stove/ lnsert/ Flreplace Unit Dryer Vent (D) N0Vent Fan Mechanical Permit lssuance State Surcharge Total Permit MECHANICAL PERM!T Furnace Exhaust Hood By signature, I state and agree, that I have caref ully examined the completed application and do hereby certify 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 Springf ietd, 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 contractors 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 is located at the front of the property, and the approved set of plans wlll remain at all tirnes during construction. 3 D.-Date MISCELLANEOUS PERMITS Mobile Home State lssuance State Surcharge Sidewalk - ft Curbcut - ft Demolition State Surcharge Total Miscellaneous Permits (E) zs 93 TOTAL AMOUNT DUE (excluding electrical) (A, B, C, D, and E Combined) {0 7€e /-G -asDATE PAID AMOUNT RECEIVED RECEIVED BY VALIDATION: RECEIPT NUMBER FT. FT, /*wr*,', Permit No:o?de g LAddress lssued Date: /'A -71 OR OFFICE USE ON 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. Fill in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 38: t. [Xt I own, reside in, or will reside in the completed structure. Z []]]E I understand that I must register as a construction contractor if the structure is sold or offered for sale before or upon completion. 3.A My general contractor is , 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. 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 lnformation Notice to Property Owners about Construction Responsibilities on the reverse side of this form. 9 D*. ?,3 d,ure o rm pplicant Date CONSTR UCTION CONTRACTORS BOARD 0244J 8t91 WHITE COPY TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT OR 4.--zov:.41/b4 INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES NOTE: i .Thjs tnf-o,ription Notice to Property Owners About Construction Responsibilities .. was developed.by the Construction Contractors Board in accordance with ORS 701.055(5), t- pdsSed:by the',1089 Orqglon Legislature lf you ire acting as your ow-n cbntractor to construct a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and areas of concern. EMPLOYER RESPONSIBILITIES: lf you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the construction or improvement of a residential structure, you will, in most instances, be ruled 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 the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Oregon Department o{ Flevenue 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 more information, callthe Oregon Employmgfi Division DHFia1378.3224,------.-.- Workers' Compensation lnsurance: As an employeri lou d[e subject to the Oregon Work5rs' 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 willbe liable for all claim costs if one of your employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 373-7434. U.S. lnternal Revenue Service: As an em ployer, you must withhold federal incorne tax from employees'wages. You will be liable for the tax payment even if you didn't actually withhold the tax. For more information, call the lnternal Revenue Service at 221-3960. Code Compliance: As the permit hqlder 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 lnsurance: 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. i lf you have additional questions, write to Construction Contractors Board 700 Summer St. NE, Suite 300 Salem, OR 97310-0151 Phone 503-378-4621 a244J 1A124189 a : -irY' :).25 trlt'-Tll s',I'Rl':lil sHuNGrIlil.l), oltl':(:01'l INSPIIGI'ION REQUIIS'I' : OFITICE: 7')-6')751) 97 47'l 7?.6-3 t 69 ON rl Nev Residentlal-SingIe or Hultl-FamilY Per dvelling unit' Servlce Incltrded: CATION Cos t $ Bs.oo $ 15.00 $ 40.00 Sum 80. ee li 00 00 00TTls s B" a566 not included) 40.00 20.00 36.00 1. LOCAT ION OP INST 3 < v-i A I,EGAL DT.SCLIPTION 92 / 13 4/n fr,N I tems 1.000 sq. f t. or less Each additlonal 500 sq. ft or Portlon tltcreoI Each Hanuf 'd llome or Hodular Duelling Scrvice or Feeder 200 amps or }ess lf" 201 anrps to /r00 amPs - 401 amps to 600 amps - 601 amps to 1000 amps- 0ver 1000 amPs/volts - Reconnect 0nIY 200 amps or less 201 amps to /r00 amps - Over /r01 to 600 amps 0ver 600 amps or 1000 JOB DESCRITIION Pcrnrits arc non-transfcrable antl cxplre It vork is not started vltlrin 180 days of issttance or if vork ls suspentlecl for 100 days. 2. CO}N'RACf,OR INSTALINTION ONLY IiIcc t rical Con t rac tot-' Add r:e ss Ci tv l'hotre Supcrvi.sor License Ntinrbcr lixpiration Date Iixpi ra t ion Da te Signaturc of Supervising Elcctrlcian 0uners Narne frl Arld rcss 3 rtaoil 5 Services or Feeders InstaIlatlon, Alteratlons or Rclocation: $ 5o.oo $ 60.00 $100.00 $130.00 $300.00 $ 40.00 Temporary Services or Feeders Insiallailon, Alteratlon or Relocatlon D ry c. E s $ s 40 55 i Ci ty I'honc 71 l-f ?0/ D. Dranch Circul ts Nev, Alteratlon or Extenslon Per Panel one clrcuit $ 35'oo Eaclr Addi t ional Circui t or r.ri th Service or Fee<ler Permit /S S 2'00 ?-& : I OVNIiN IN:;'I'ALLATION Tlre ilrstallation is being made on property I ovn vhich is not interrded for sale, lease or rent. o ers a DATE: RNCIIIPT 14iscellaneotrs ( Servlce/ feeder -Eaclr installation Plrmp or irrigation $ Sign/ourline Ligtrting- $ Limi ted Energy/Res - S Liml ted nnergy/Comrn - S SUDTOTAL OT ADOVB 5f State Surcharge TOTAI, LS\ IIIi(:IiIVI]1) IIY: 5 nnEo1ffi -(u 4? so qfi, 4