HomeMy WebLinkAboutPermit Building 2008-8-5
-G7~
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Status
Issued
225 FIfth Street, Spnngfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 InspectIOn LIne
CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO
ISSUED
APPLIED.
EXPIRES:
VALUE.
COM2008-00985
08/05/2008
07/03/2008
02/05/2009
$ 180,330 00
SITE ADDRESS 3161 DOUGLAS DR
ASSESSOR'S PARCEL NO 1802062109500
SPRINGFIETYPE OF WORK SIngle Family Residence
TYPE OF USE
New
ResIdential
PROJECT DESCRIPTION SIngle famIly reSIdence
Owner DJS INVESTMENTS LLC
Address 2860 MARTINIQUE AVE
EUGENE OR 97408
Contractor LIcense ~XPlratlOn Date
DJS INVESTMENTS "'~NTION Oregon la,^,W~\I1es Y~IIi~Y 10/09/2008
BOB FISHER ELEC1f~'&Jlll&les adopted by '9\l2~eir~~et forUf1/25/2010
MARSHALLS INC Notification Center Th~S~~AR 952_001J2/2312009
JAMMAL INC In OAR 952-001-001_~.: !.?V~~tl'Je rules bf1/12/2010
riiTiiLDl.N6,;,rPh"'~M ~i telephone
nu ber 107ih~ U~e~UI,I,~ Notification
li"of~\te; IS 1-800-332-2344)'1 Lot SIZe
HeIght of Strncture 1900 Sq Ft 1st Floor
Type of Heat Forced Air Gas Sq Ft 2nd Floor
Water Type Gas Sq Ft Basement
Rdnge Type Gas Sq Ft Garage/Carport
Energy Path Path 5 Sq Ft Other
Spnnkled BUlldmg No Occupant LOdd
Contractor Type
General
Electncal
Mechamcal
Plumbmg
# of Umts
Pnmary Occupancy Group
Seconddry Ocenpdncy Group
Pnmdry Construction Type
Secondary Construction Type
# of Bedrooms
Frolltyard Setback
SIde 1 Setback
Side 2 Setback
RearYdrd Setbdck
Solar Setbacks
Street Improvements
Storm Sewer Available
Specldl InstructIOn
A..tCP-~
~
I CONTRACTOR INFORMATION I
Phone
541-485-2655
541-689-7973
541-747-7445
541-484-7440
R-3
U
VB
1,507
520
3
I DEVELOPMENT INFORMATION I
REQUIRED PARKING
2
1800
600
600
2250
000
OverldY Dlst Total
# Street Tre~.Rqd 2 t W~dlcapped
P dvflM!-GtrEqd \. Et.?1l\e\lS 1l'\ '('PdCt
% olfrtlSCFil?Ml\l Sl-\~~R iHIS'~tiV.MIT IS
lI.UiHORI7..ED_ U~~ Ie: ABANDONED fOR
I PUBLIC 1~1"~'IIRIOD.
,...l(.'~'
F II I d Sidewalk Type
u V mprove
Yes
Downspoutsmralns
CurbSide 5'
To Storm Sewer
Notes Stormwater to weep hole m curb
Page I of 4
-~
Status
Issued
225 FIfth Street, SprIngfield. OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 InspectIOn LIne
DeSCriptIOn
Tvpe of ConstructIOn
A C - Reslden
Dwelhn2s
Garae:c
AC - Resldenl1al
V Wood Frame
Gard2.c
Fee DeSCrIptIOn
-Mech Iss 2+ Apphances-
+ 10% Admlmstral1ve Fee
+ 12% State Surcharge
+ 5% Technology Fee
2 Bdths One or Two Family
AddreSSIng ASSIgnment
Apphance Vent
BOller/Comp Up To 100,000 btu
BUIldIng PermIt
Curbcut PermIt
Dryer Vent
Exhau;t Hoods
Fire SF Fee - Resldenl1al
Furndce - up to 100,000 btu
Gas Outlets 1-4
Plan ReVIew MaJor - PlannIng
Plan ReVIew Resldenl1al
ResIdence WIrIng 1000 Sq Ft
ResIdence Wiring Ea Addtl 500
Samtary Sewer - Improvement
Samtary Sewer - Relmbnrsement
SDC MWMC AdmInlstrdtlOn
SDC MWMC Improvement
SDC MWMC ReImbursement
SDC Samtdry/Storm AdmIn
SDC Trdn;po Improvement
SDC Tr dnspo ReImbursement
SDC Transportdtlon AdmIn
S,dewalk PermIt
Storm Dramage ImpervIOUs Area
Storm Sewer Each Addtll00'
Temp Power 200 dmps or less
Vent Fan
Wlllamaldne SIngle Family
I ValuatIOn Descrmhon I
$ Pel Sq Ft
or mull1pher
$500
$10500
$28 00
Square Footage
or BId Amouut
1,50700
1,50700
520 00
Totdl Value of ProJect
FpP~, P'll~
Amount Pdld
$40 00
$16392
$18454
$96 24
$280 00
$35 00
$700
$1400
$912 82
$88 00
$700
$1000
$10135
$1400
$500
$211 00
$593 33
$11700
$63 00
$483 84
$636 30
$10 00
$1,009 17
$97 90
$14342
$888 98
$201 54
$73 44
$88 00
$1,00942
$32 00
$55 00
$2100
$2,513 00
Date PaId
8/5/08
8/5/08
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Pa2e 2 of 4
CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO. COM2008-00985
ISSUED' 08/05/2008
APPLIED. 07/03/2008
EXPIRES: 02/05/2009
VALUE. $ 180,33000
Value
Date Calculated
$7,53500
$158,235 00
$14,560 00
$180,33000
07/08/2008
07/03/2008
07/03/2008
ReceIpt Number
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
1200800000000000841
CITY OF SPRINGFIELD
Building/Combination Permit
Status
Issued
PERMIT NO' COM2008-00985
ISSUED: 08/05/2008
APPLIED. 07/03/2008
EXPIRES. 02/05/2009
VALUE' $ 180,330.00
225 F,fth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 InspectIOn LlOe
Total Amount PaId
$10,20621
Plan Revtews I
Planmnc RevIew 07/03/2008 07/03/2008 APP TAJ
Public Works RevIew 07/03/2008 07/03/2008 APP LKW Stormwater to weep hole 10 curb
Structural RevIew 07/08/2008 07/08/2008 APP DLM See documents for Plan review
comments
To Request an IDspectlOn call the 24 hour recording at 726-3769. AlllDspectlOns requested before 7.00
a.m. wIll be made the same working day, IDspecttons requested after 7:00 a.m. wtll be made the following
work day.
I Rpnlllrprl 'n~,np~hon~, I
ErOSlOn/GrddlOg InspectIOn Prior to ground dIsturbance and after erosIOn measures are Installed
SIdewalk - CurbsIde After lorms arc erected but pI \Or to placement of concrete
Curbcut - Standard After forms are erected but prior to placement of concrete
Ufer Electrical Ground Install ground rod at footIng and call for IOspeetlOn 10 conJunchon wIth footIng and/or
foundatIOn IOspectlOn
FootlOg After trenches dre excavated
FounddtlOn After forms are erected but prior to concrete placement
Post dnd Bedm Prior to Iloor InsulatIOn or decklDg
Floor InsuldtlOn Prior to deckIng
Shear Wall NaIllDg Before covering sheath 109 wIth fimsh materials
FramlDg InspectIOn Prior to cover and after all rough 10 IDspectlOns have been approved
W dll InsulatIOn Prior to cover
Ceiling Insulation Prior to cover
Drywall Prior to taplOg
Hold Downs Installed SpecIal Inspechon performed prior to placement of concrete ProvIde report to CIty
BUIldIng Inspector
FlOdl BuIldlDg After all reqUIred IDspectlOns have been requested and approved and the bUIldIng IS complete
Undellloor PlumblOg Prior to IOsulatlOn or decklDg
Underfloor DrdlO Prior to cover or placement of concrete
Rough PlumblOg' Prior to cover and IOcludIng reqUIred test 109
Water LlOe. Prior to filling trench and IDcludlDg reqUIred testlDg
Pace 3 of 4
CITY OF SPRINGFIELD'
Building/Combination Permit
Status
Issued
PERMIT NO: COM2008-00985
ISSUED: 08/0512008
APPLIED' 07/03/2008
EXPIRES. 02/05/2009
VALUE: $ 180,33000
225 FIfth Street, Spnngfield. OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769Inspeellon LIne
SJnltary Sewer LIne Pnor to filhng trench and mcludmg reqUIred testmg
Storm Sewer Lme Pnor to filhng trench
Fmal Plumbmg When all plumbmg work IS complete
Underfloor MechJnlcal Pnor to msulatlOn or deckmg and mcludmg reqUIred testmg
Underfloor Gas After hne IS mstalled and required testIng and capped If not attJched to an apphanee
Rough Gas After hne IS mstalled and required testmg and capped If not Jttaehed to an apphance
Gas ServIce Alter hne IS mstalled and hne has been connected to a mmlmum of one apphJnce IncludIng reqUIred
testmg Presure test done at thIS pOInt
Rough Mechanical Pnor to Cover
Fmal Gas When JII gas work IS complete
Fmal Mechanical When all mechanical work IS complete
Temporary Eleetnc ApproVJI reqUIred pnor to Utlhty Company energIzIng pole
Rough Electne Pnor to Cover
Electnc ServIce Approval required pnor to utlhty company energIZIng servIce
Fmal Electnc When all eleetncal work IS complete
By slgnJture, 1 state and agree, that I have carefully examIned the completed apphcatlOn and do hereby certIfy that all
IIIformatlOn hereon IS true and correct, and 1 fnrther certIfy that any and all work performed shall be done m accordance wIth
the OrdInances of the CIty of SprIngfield and the Laws 01 the State 01 Oregon pertammg to the work descnbed hereIn, and
that NO OCCUPANCY WIll be made of any structure wIthout permISSIOn of the Community ServIces DIVIsIOn, BUIldIng Safety
[ further cerllfy that only contractors and employees who are m comphance wIth ORS 701 005 wIll be used on thIS project
[ fnrther agree to ensnre that all reqUIred mspectlOns are reqnested at the proper lime. that each address IS readable from the
street, that the ermlt card IS located at the front of the property. and the approved set of plans wIll remalll ou the sIte at all
t~7 g constr tlOn ~___________ __ 8 _ S- ~d 8
'>-----= ~
Owner or Contrdctors Signature Date
PJee 4 of4
~~ Willamalane
t'\j Park & Recreation District
Job No /' 1JJ417LJl)8 - hO '9 ~ 5
SYSTEM DEVELOPMENT CHARGE WORKSHEET FOR 2008
NAME 7)J 5 1N/)ESTMc.A'r.r PHONE 5/7- '55"SO
- .
ADDRESS ~~/1Iht.77J1I(lut! CITY E..M~ STATE MZIP 97-1/)<6
LOCATION OF PROPOSED BUILDING SITE
Street Address
? /6 1- 7)opc; LA. \" lw
Plat Name )/ITrAtt 41~ Tax Lot Number '~t!JZt")(;,2-/ o95tJo
1 DEVELOPMENT TYPE, (Check appropnate dwelltng(s) Dwelling type defintllons are on the
back)
A Smole-Famllv Detached.
NO OF UNITS X $2,513 per Unit = $ 2 ~ /8
B Smole-FamJlv Attached
NO OF UNITS .X $2,726 per unit = $
C Multl-Famllv Aoartment
NO OF UNITS X $2.323 per Unit = $
D Smale Room Occuoancv
NO OF UNITS X $1.162 per Unit = $
E Accessorv Dwelhna Unit
NO OF UNITS X $1.257 per unit = $
WILLAMALANE SDC $
2. SDC CREDIT (If appltcable) SDC payer must furnish proof of
Willamalane Credtl approval) $
3. TOTAL WILLAMALANE NET SDC ASSESSED
(If SDC reduced for Credtl) $ 2<5/3
Dt<; g I S- I 07
Development Services Department Date
City of Springfield
5
ZON~
INITIALS. .
DATE 1,.,.Ob
SOURCE~ C~/1..-'
22~ FWfH S IIU.ET . SPRINGFIl.LD, OR 97477 . PlI (541)726-3753 . FAX (541)726-3689
ELECTRICAL PERMIT APPLICATION
CIty Job Number Lewt ?=OX- - 00 '7 B j
2 CONTRACTOR INSTALLA1IO!" ONLY B Serv.ees or Feeders - InstallatIOn, AlteratIOns or RelocatIOn
ElectrIcal Contractor Pc) (') h;, It e-v n L-- iP- J C- 200 Amps or less aU \0 $ 70 00
201 ~~.M~~~~ $ 83 00
Address / 'I, l) r.( 1// y _" f, M/ I ( 7J Y-c. 1-\ OleCd~~\'lllQb~ Se\1\Q~. $138 00
~€.I'I\\~s a.dO?te~~t~~13\)'f $18000
CIty tirx... ~_, Phone br;;~~~cefl\~6{&\\111 ~~bl\e $41300
I - r Jh.. b ~f.O~ sp8;OO\' o'O~~~, \Vlli~e\~~oe.\\OI\ $ 55 00
\1'1 0 ,/011 {l'Ia.'/ efl\el. \1'11'1\1\\\\\'/ I'I~\
SupervIsor LIcense Number '7 Cf?S- .'90:^'\\f1Cd \ne ~n'6 OI~I~~:ces or Feeders
~~{l'I'Oel \~~\el \5 ..-8
/(') _ \ 0 _ (t? C Installahon, AlteratIOn or RelocatIOn
200 Amps or less
201 Amps to 400 Amps
401 Amps to 600 Amps
I LOCAl ION OJ; INS1ALLAlION.
3(b( 1~-..IA< I~Q....
LEGAL DESCRJPTlON
feot. 6f>Z-\
JOB DESCRIPTION
;-1-0 '^ S t!
o 9 FO c::>
Lo/ rile
Permits are non-transferable and expire .fwork IS
not started withIn 180 days of Issuance or If work .s
Suspended for 180 days
EXpiratIOn Date
Constr Contr Number
9/. '2-7'-7
ExpIratIOn Date
J()- 10
- D'1
Signature of SupervIsIng ElectncJan
_~{?6- J-::rd~
~ ...e-r~",^L_ +-
vW.Att.TI.v'~
Owners Name ":h T <"
Address ZSbO
CIty P c.A.{, ~""r
Phone 50- S -'>}'o
OWNER INSTALLATION
The InstallatIOn IS beIng made on property 1 own whIch
IS not mtended for sale, lease or rent
Owners SIgnature
InspectIOn Request 726-3769
Date
3 COMPLETE FJo.E SCHEDULE BELOW
A
New Resldenhal- SIngle or Mulh-Fam.ly per dwellIng UDlt
Serv.ee Included
1000 sq ft or less
Each addItIOnal 500 sq ft or
portIOn thereof
Each Manufact'd Home or
Modular Dwellmg ServIce or
Feeder
I
"5
$ 2100
$11700
//7
63
$55 00
$ 55 00
$ 76 00
$110 00
Over 600 Amps or 1000 Volts see "B" above
D Branch CirCUIt.
New AlteratIOn or ExtenSIOn Per Panel
One CIfCUIt
Each Addl110na1 CrrcUlt or wIth
Servlce or Feeder Permit
$ 48 00
$ 400
E MIsccli;.neo-u, (Sen .ee/feeder nO..l.~~~Each Installation
~\?~ \~ 1 \S ~O\
.I."~~~~ ~~f>.\.\. T."~\S ~t?~" tOW 55 00
m~~ ~~~? \ ~~t)(\~~\) $ 55 00
~~~ ~~lfD~~ $ 28 00
Lle~~ ~~Q. $ 50 00
Mmlmu,,~~ erm.t Inspechon Fcc IS $50 00 + Surcharges
4 SUBTOTAL OF ABOVE / c5 0
12% State Surcharge ZIt>'-'
10% AdmInIstratIve Fee /8
5% Technology Fee 0;
22B~
TOTAL
Shared Dnve(T )/Bulldmg fonns/EleetTlcal Penmt ApplicatIOn 1-08 doc
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT WORKSHEET
-
JOURNAL OR JOB NUMBER
NAMC OR COMPANY
LOCA I ION
TAX LOT NUMBER
DEVELOPMEN I rYPE
NEW DWELLING UNITS
COM2008-00985
DJS Investments
3161 Douglas
1802062109500
Smgle Family Residence
I BUILDING SILE (SF
2027
I Sl ORM DRAINAGE
DIRECT RUNOfF TO CITY STORM SYSTEM
I IMPERVIOUS S F x I COS f PCR S F CHARGE
282950 i $0357 I = I $1,00942 I
RUNOFF ROUl CD TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY S fANDARDS
I IMPERVIOUS S F I x COST PCR S F I x I DISCOUNT RATE I I
I 0 00 I $0 357 50% I ~ I
ITEM I TOTAL - STORM DRAINAGE SDC
2 SANITARY SCWER - CITY
A REIMBURSCMFNT COST
I NUMBER OF DFU's I x
I 23 I
B IMPROVEMeNT COST
I NUMBCR OF DFU's I x
I 23 I
$1,00942
COS I PER DFU
$27 67
COST PER DFU
$2104
~ ,
3 TRANSPORIATION
ITEM 2 TOTAL - CITY SANITARY SEWER SDC
$1,12014
LOT SIze (Sf)
o
DISCOUNl
$000
$1,00942
$636 30
$483 84
'r-'
1m
W
10
'0
u
~
W
II-
-1"00
(3
~
I
I t070
I t09t
I
11092
I
I
DRAINAGE FIXTURE UNIT (DFU) CALCULA nON TABLE
"._~~'--- ....
NUMBER OF NLW FIXTURES x UNIT FQUIV ALLNT - DRAINAGE FIXTURL UNITS
(NOTE FOR RCMODFLS CALCULATE ONLY THE ~I ADDITIONAl FIXTUR~S)
NO OF FIXTUR~S DRAINAGE
UNIT r!XTlJR~.
FIXTURE TYPE NEW OLD IoQUIV Al I NT UNITS
IBATIIIUB 1 0 3 = 3
IDRINKING FOUNTAIN 0 0 1 = 0
I FLOOR DRAIN 0 0 3 = 0
IINTIoRCEPTORS FOR GREASE lOlL I SOLIDS I ETC 0 0 3 = 0
INTIoRCEPTORS FOR SAND I AUTO WASIl IIoTC 0 0 6 = 0
I LAUNDRY TUB 0 0 2 = 0
ICLOTIlESW Asm R I MOP SINK 1 0 3 = 3
ICLOI!lESWAS!lER - 3 OR MORt (EA) 0 0 6 = 0
MOBILE IlOM! PARK TRAP (l PI R TRAJLIoR) 0 0 12 = 0
I RECFPTOR FOR REFRIG I W A TIoR STATION I ETC 0 0 1 = 0
IRECH' roR FOR COM SINK I DlSHWASIILR I ETC 1 0 3 = 3
I SHOWER. SINGLE STALL 1 0 2 = 2
I SHOW~ R. GANG (NUMB~_R OF HEADS) 0 0 2 = 0
ISINK COMMI RCIALiRESIDENTIAL KJ'iuIEN 1 0 3 = 3
ISINK COMMERCIAL BAR 0 0 2 = 0
SINK WASH BASIN/DOUBLE LAVATORY 1 0 2 = 2
ISINK SINGLE LAVATORYIRESIDENTIAL BAR 1 0 1 = 1
IURJNAL, STAI I IWALL 0 0 5 = 0
ITOlLlol PUBLIC INS I ALLATION 0 0 6 = 0
ITOILIo T, PRIVATE INS f ALLA TION 2 0 3 = 6
MISCr! LAN~.OUS DFU TYPE NUMBER Of IoDU'S :~
20 =
TOTAL DRAINAGE FIXTURE UNITS
.EDU (bqUlvalent Dwelhng Unit) IS a discharge eqUIvalent to a smgle famIly dwelling umt (20 DFlJ~) set at 167 gallons per day
MWMC CREDIT CALCULA nON TABLE BASED ON COUNTY ASSESSED VALUE
r! YEAR I CR~ DlT RA TE/$I ,000 ~
ANNEX~.D ASSLSSED VALUE IS LAND LLGlBLE FOR ANNI XA TION CREDI P 2
BEFORF 1979 $529 (Enter 1 for Ye" 2 for No)
I t979 $529 IS IMPROV~ MENT FI GlBLF FOR ANNEX CRfDI'f? 2
1980 $519 (Enter I for Yes 2 for No)
I 1981 $512 BASE YEAR 1979
I 1982 $498
I 1983 $4 80 CREDIT FOR LAND (IF APPLlCABU)
I 1984 $463 V ALliE I 1000 CREDIT RA 11.
I 1985 $440 $000 x $529 ~ I $000
I 1986 $407
I 1987 $367 CR~ DlT fOR IMPROVEMENT (IF AFrER ANNIoXA nON)
I 1988 $322 VALUE 11000 CREDIT RATio
I 1989 $273 $000 x $529 0
I 1990 $225
I 1991 $180
I 1992 $159 TOTAL MWMC CREDIT = $000
I 1993 $145
1994 $125
I 1995 $109
I 1996 $092
I 1997 $072
I 1998 $048
1999 $028
,: 2000 $009
2001 $005
RECEIPT #. 1200800000000000841 Date' 08/05/2008 II 36 31AM
Job/Journal Number DescrIption Amount Due
COM2008-00985 Pldn Review Major - PlannIng 21100
COM2008-00985 Sidewalk PermIt 8800
COM2008-00985 Curbcut PermIt 8800
COM2008-00985 SanItary Sewer - ReImbursement 636 30
COM2008-00985 Sanitary Sewer - Improvement 483 84
COM2008-00985 Storm DraInage ImpervIOus Area 1,00942
COM2008-00985 SDC Transpo Reimbursement 20154
COM2008-00985 SDC Transpo Improvement 888 98
COM2008-00985 SDC MWMC ReImbursement 9790
COM2008-00985 SDC MWMC Improvement 1,00917
COM2008-00985 SDC MWMC AdmInIstration 1000
COM2008-00985 SDC SanItary/Storm AdmIn 14342
COM2008-00985 SDC TransportatIOn AdmIn 7344
COM2008-00985 Plan Review ResidentIal 593 33
COM2008-00985 BUlldlOg PermIt 91282
COM2008-00985 AddressIng Assignment 3500
COM2008-00985 WIlIamalane SlOgle FamIly 2,51300
COM2008-00985 2 Baths One or 1 wo Family 280 00
COM2008-00985 Storm Sewer Each Addtl 100' 3200
COM2008-00985 Furnace - up to 100,000 btu 1400
COM2008-00985 BOller/Comp Up To 100,000 btu 1400
COM2008-00985 Vent Fan 2100
COM2008-00985 ApplIance Vent 700
COM2008-00985 Exhaust Hoods 1000
COM2008-00985 Dryer Vent 700
COM2008-00985 Gas Outlets 1-4 500
COM2008-00985 -Mech Iss 2+ ApplIances- 4000
COM2008-00985 FIre sr Fee - ResIdential 101 35
COM2008-00985 ResIdence WIrIng 1000 Sq FI 11700
COM2008-00985 ResIdence WIrIng Ea Addtl 500 6300
COM2008-00985 Temp Power 200 amps or less 5500
COM2008-00985 + 5% Technology Fee 9624
COM2008-00985 + 12% State Surcharge 18454
COM2008-00985 + 10% AdmInIStrative Fee 16392
Item Total $10,20621
Payments Check Number AuthorizatIOn
Type of Payment PaId By Received By Batch Number Number How Received Amount Paid
CredltCard DALC KAS r dJb 08182C In Person $9,50000
Check DJS INVESTMENTS LLC dJb 5938 1 n Person $706 21
Paymeut Total $10,20621
cRecemtl
Page 2 of2
8/5/2008