HomeMy WebLinkAboutPermit Mechanical 1994-9-14
r
Pfo._
RESIDENTIAL
PERMIT APPLICATION
Inspections: 720.3769
Office: 726.3759
cz-a. LI Pa M\~
SPRINGFIELD ,..
it- I"
LOCATION OF pnOPOSED wonK: __33JJ3_f1Jt_Wf\ov\
ASSESSORS MAP'
'f
LOT:
1)0..,(\1 +
Lt. '2,1 (JOf
Srrl~.
DEscnlBE WORI<"' --rl\'l~d
NEW Y REMODEL
OWNER:
ADDRESS'
CITY:
QllAD AIlEA:
. OF BLDGS: __ _
occv Gnoup:
" OF STORIES: __
WATER HEATER:
BLOCK:
v "<- k'.\~J 5 h ('f\!(A
1111' <.I~Y\ QJ.
STATF'
Or
WP 1031.[~-)Wl/
JOB NUMBER Cft.! /i. /6
225 Fifth Street
Springfield, Oregon 97477
, I
(V)U~,k... hoMF
t-{ ev..,'1
eJ
5~"l.JJ 0 r
TAX LOT:
SUBDIVtSiON:
PHONF'
7lf(r C/8'lf
ADDITION DEMOLISH
f'JtN v>o-I>
I
OTHER
ZIP:..2!fJ7 ~
ADDRESS
CONST,
CONTRACTOR'
7
PHONE
REQUIRED INSPECTIONS
D Rough Mechanical - Prior to
cover.
D Rough Electrical - Prior to
cover.
D Electrical Service - Must be
approved to obtain permanent
electrical. power.
CI Fireplace - PrIor to facing
111111erlals and framIng Insp.
1=1 Framing - Prior to cover.
D Wall/Ceiling Insulation - Prior to
Gover.
D Drywall - PrIor to taping.
D Wood Stovo - After Installation.
D Insert - After fireplace approval
and Installation of unll.
,
D Curbcut & Approach - After
forms are erected but prior to
placement of concrolo.
D Sidewalk & Driveway - After
excavation Is complete, forms
and sub-base material in place.
D Fence - When completed.
D Street Trees - When all required
trees are planted.
EXPIRES
I )/;J{ / 'l't
I
~ 4Cf"do/8/
CONTRACTon's NAME
GENERAL _~\b~ Hf)
::~C::~~C~~L: ~~-~~\(; ~-t:~~
1..[).Q7 t,J 6 "-h
705l{)'
FLOOD PLAIN:
ZONING CODE:_
. OF BDRMS:
SECONDARY HEAT:
SQUARE FOOTAGE:
To request an Inspection, you must call 726-3769. This Is a 24 hour recording. All Inspections requested before 7:00 a.m. will be
ITlncle the same working day, Inspections requested after 7:00 8.m. will be made the following work day.
D Temporary Electric
r I SlIe Inspection - To be made
after excavation, but prior to
setting forms.
D
Underslab Plumbing/ Electrical/
Mechanical - Prior to cover.
(~ Footing - After trenctlCs are
cxcavntfJ(L
D
Mnsonry - SlrJul location, bond
bearns, oroutinu.
D
Found,atioll - Aftor forlllS arc
erected but prior to concrete
pl,lcefllcnt.
D
Underground Plumbing - Prior
to filling trench.
D
Undertloor Plumbing/Mechanical
_ Prior to Insulallon or decking.
D Post and Beom - Prior to floor
insulatIon or decking.
D Floor Insulation - Prlor to
clecklng. ,
D Sanitary Sewer - Prior to fillIng
trench.
D Storm Sower - Prior to filling
trench. .
D Water Line - Prior to filling
trench.
o Rough Plumbing - Prior to
cover.
- OFFICE USE -
LAND US~:
h OF UNITS:
CONSTR. TYPE:
HEAT SOllRCE:
RANGE:
D
Final Plumbing - When all
plumbing worle Is complet,c.
D Finol Electrical - When all
electrical work Is complete.
~5,7S
F::/1 Final Mechanical - When all
~ mechanical work Is complete.
D Flmll Building - When all
required Inspections hnvc been
npproved ilnd building Is
completecL
DOther
MOBILE HOME INSPECTIONS
D Blocking and Set. Up - When all
blocking Is complete.
D Plumbing Connections - When
home has been connected 10
water and sewer.
I'
D Electrical Connoction - When
blocking, set-up, and plumbing
Inspections have been approved
and tho home Is connected to
the service panel.
!':'
D Final - After all required
Inspections are approved and
porches, skirting, decks, and
venting have been Installed.
"
,
"
<,.!
lot faces Lot TYP'- Setbacks
Lot sq, fig, Interior P,l. HSE QAR ACC
lot coverage Corner ..!:L.- _ __
': ~----
Topography Panhandle
Total height Cul.de-sac .':!L... _ --
. ~ THE PI,OPOSED W~RK IN THE
.. HISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTEI,?
If yes, thIs applicallon must be signed
and approved by tile Historical
Coordinator prior to pC/mit issuance.
'1
IE
BUILDING PERMIT
ITEM SO. FT. X $/SO, FT, VALUE
Main
Garage
Carport
I
Total Value
Building Permit Fcc
State Surcharge
Total Fcc (A)
SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
PLUMBING PERMIT
ITEM
FEE
FIxtures
ResIdential Bath(s) NO
Sanitary Sewer FT.
Water FT,
Storm Sewer FT,
Mobile Home
Plumbing Permll
State Surchnrgc
Total Charge
(C)
MECHA~JC.l}L ~RMIT
~ Hifrt- rump
Exhaust Hood
Vent Fan
N'
Wood Stove/lnsertl Fireplace Unit
Dryer Vent
Mechanical Permit
tAM
15,0f)
10,00
.7S-
.J:I. . '(5"
'tf 2-S ,7q..
I
Issuance
State Surcharge
-;<,.010 Adl'Vli "l'i:llm-h ve..
ToYa( 'Permit
Fe.<-.
(D)
MISCELLANEOUS PERMITS
I
Mobile Home
State Issuance
State Surcharge
Sidewalk
It
Curbcut
It
Demolition
State Surcharge
Total Miscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding olectrical)
(A, B, C, D, and E Combined)
L-..J
APPROVED'
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on the express condition that the said
construcllon 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.
Plan Check Fcc:
Date Paid:
Receipt Number'
Received By:
Plans Reviewed By
o31e
Systems Development Charge Is due on all undeveloped
properties within the City limits which are being improved.
ADDITIONAL COMMENTS
By signature, I stale and ngree, Illal I have carefully cx~mincd
the completed applicntion and do hereby cerliry that all
information tlCreon is Irue and correct, and I further certify
that any anu all work performe(l shall be done in ilccordance
with the Ordinances of the City of Sprlnglleld, and the Laws
of the State of Oregon pertaining to the work described
heroin, and that NO OCCUPANCY will 'be made of ilny
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 thls
project.
I further agree to ensure that all required inspeclions are
requested at the proper time, that each address is readable
from the street, that tile permit card Is localed at the front
of the properly, and the approved set of plans will remain
~~~~;;;~'~~;;/;/in~~~;;~if-~'
Dat"U tJ- If/- 9l-/ IJt( 1J1#f/ /
I
VALIDATION:
RECEIPT NU~B~~..! ,L/lol.o
DATE PAID ~t:r:L
AMOUNT REC7~VfD -25 -.(~
RECEIVED BY jlXI / - b JlA~
.
fi y!i!I.f!,';!!!!~~
.
Job No. 9.i!...2/s;-
SYSTEMS DEVELOPMENT CHARGE
WORKSHEET
NAME:
~ / ,') /Mli:::t/,,={'"
PHONE: 7~& -77- ~ :s
ADDRESS:
44/
,Jecrr .)/"i
,
STATE:M ZIP 3 "'74 ? 7
LOCATION OF Ii'ROPOSED BUILDING SITE:
Street Address if Known: 4 L,r";J C; ~ /~ Y~.J
Platt Name:
Tax Lot Number: /~t) 2 :!::~ 0 / """'~~
1. DEVELOPMENT TVPF, (Check appropriate dwelling(s). SDC Calculations and dwelling type
definitions are on the back'>
A. Sim!le Familv - Detached
Single Family home
NO OF UNITS I
.
B. SinQle Familv - Attached
NO OF UNITS
C. Multi-Familv Apartment
NO OF UNITS
D. Manufactured Home Park
NO OF UNITS
WPRD SDC
~ufactured home not in a park
$ ~ tf-t)
X $400 PER UNIT _=
.
X $370 PER UNIT =
'$
X $277 PER UNIT =
$
X $280 PER UNIT =
$
$p~
2. SDC CREDIT (If applicable) SDC-payer must furnish proof of WPRD Credit
approval. See sac Credit Worksheet.
3. TOTAL WPRD NET SDC ASSESSED (If sac reduced for CrediO
Community Services Division
City of Springfield
$
$ 4()tJ <t-o
( ,
I I
Date
.
'\
spnoNclLO
I 225 ur.o STREET ' The following pro)acl ssaubmllted nas Ine ldDbIlIllfRICAL PERMIT APPLICATION
SPRINGFtELD, OREGON 974Thoning, and dooa nol ,squire epeciftc land use a J
.' INSPECTION REQUEST: 726J!mPJsl. L'Dt'Z- Ci ty Job Number I 4> I Z 1<)
OF~CE: 726-3759 Zoninp , ,
J. CuMPLETE FEE SCDEDULE BELOV
1: LOCATION OF INSTALLA'l1l1O"'
4.-2,t'f=; J-'M,T ///)I7~~"lgno."rA (\ rf..
LEGAL DESCRIPTION
J?1FJ 2 OS :2. / IJe,BOV
JOB DESCRIPTION
Permits are non-transferable and expire
if work is not started within 180 days
of issuance or if work is suspended for
180 days.
2.' CONTRACTOR INSTALLATION ONLY
" .
Electrical Cont~~ctorJ+F-~r\A.&F-_l;:l~
,,(~'tZ- ~ .'"' , " .
Address t1t.n ,.~- ~4 P'" 1\ II r_
7Z--'1 -l'5DO
Ql\"'iS ~ff-/b<nJ
Nell ResidenJial-Single or
HUlti-Family per dwelling unit.
Service Included:
It ems Cost Sum
1000 sq.ft. or less $ 65.00
Each additional 500
sq. ft or portion
thereof $ 15.00
Each Hanuf'd !lame or
Modular Dllelling
Service or Feeder 2- $ 1,0.00 ~
Services or Feeders
Installation, Alterations
or Relocation:
B.
Ci ty _1="11' i? --1\1 E- Phone
Supervisor Licen~e Number
200 amps or less
201 amps to 400 amps
401 amps to 600 amps
601 amps to 1000 amps
Over lOOO amps/volts
'21r--(,)(J Reconnec t Only
Expiration Date
to .-\ -9<=')
Constr Contr. Number (03\"J1
Expl'ration Date \'2..-2'1-Cj,3
Signature of Supervising Electrician
~cJ.~
. I
Owners Name {{~/---4)7'AW/21/L}_
Address #1 "'Y-V Yr:
City Phone
. OVNER INSTALLATION
The installation is beirig made on
property I own which is not intended
for sale, lease or rent.
.
Owners Signature:
"
----------------------------------
.' ,
DATE: ,
RECEIPT, I: .
RECEIVED BY:
$ 50.00
$ 60.00
$100.00
$130.00
$300.00
$ 40.00
C.
Temporary Services or'Feeders
Installation, Alteration or Relocation
200 amps or less
201 amps to 400 amps
Over 401 to 600 amps
Over 600 amps or 1000
D.' Branch Circuits
volts
$ 1,0.00
$ 55.00
$ 80.00
see "D"
above
New, Alteration or Extension Per Panel
Miscellaneous (Service/feeder
-Each installation
Pump or irrigation
Sign/Outline Lighting
Limited Energy/Res
Limited Energy/Comm
One Circuit
Each Additional
Circuit or lIith Service
or Feeder Permit
E.
5.
SUBTOTAL OF ABOVE
5% State Surcharge
TOTAL
"
$ 35.00
$
2.00
not included)
$ 1,0.00
$ 40.00
$ 20.00
$ 36.00
6fJP"D
-9-0~
"2. ~
'bro/!o
/
_O~ ~o."li/2/ s-
" '
. ' .
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE
WORKSHEET
(COHHERCIAL & RESIDENTIAL)
IWIE OR COMPANY: . /S~ ". !~~A~ 5~
LOCATION' 430'1 J1t/. )t/"~ '
DEVELOPMENT TYPE: ~.kJ /I~ ~
I' /
BUILDING SIZE: (.4j',;r ;1.1')+(.J.5:':f?').{..H~J1') I OT SIZE'
HOIAS& all</ c;,..lM~
1. ~TnRM ORAINAGE
.
"ATTACHMENT B1
SQ. Ft.
IHPERVIOUS SQ. FT.
2/1'; ;t
X $0.209 PER SQ. FT. S 44tJ3C-
2. SANITARY SFWFR-r.TTY
NO. OF PFU'S
(See Reverse)
/'6
X $43.26 PER PFU
S II,?-, ~
3. TRANSPORTATION
NO OF UNITS X TRIP RATE X COST PER TRIP
X
X
X $436.19
X $436.19
~ #o,s,s-
S
I
X /,0/ X $436.19
S
SUBTOTAL (ADD ITEMS 1.2. & 3) S /(..59.5'''1
4. SANlIARY SFWFR-MWMr.
NO. OF PFU'S 16' x $17.19 PER PFU + $10 MWMC ADMIN.FEE S 3/'1, ~<
(Use PFU Total From Item 2 Above)
MWMC CREDIT IF APPLICABLE (SEE REVERSE) $ 4..,. S" ~
IQIAI -HWMC Sue S :2 ;rl'. 'ilS-
SUBTOTAL (ADD ITEMS 1. 2 .3 & 4) S / 9' '31. -f-1"
5. ~nMTNTSTATTVF FFFS
BAS CHARGE ,<;UB~ ABOVE) X .05
~ Date:
- Hornig, R.E) .
oordinatoY
~ 9~J7
?-/o-"'1~
IQIAI snr,
s .20.2...8'.0/
B2.SDC .
fiXTURE UNIT CALCUL~N TABLE: Number of New Fixi.u~l( E'q\livalent = Fixt~re Units,
(NOTE: For remodels, calculate only the NEI additional fixtures) " , I ,
NUMBER Of UNIT FIXTURE
FIXTURE TYPE NEW FIXTURES EQUIVALENT UNITS
Bathtub..................................................................... .
Drinking Fountain.....................................................
Floor Drain................................................................
Interceptors For Grease/Oil/Solids/Etc.................
Interceptors For Sand/Auto Wash/Etc..................
Laundry Tub/Clotheswasher...................................
Clotheswasher. 3 Or More.....................................
Mobile Home Park Trap (1 Per Trailer)..................
Receptor For Refrigerator/Water Station/Etc........
Receptor For Commercial Sink/Dishwasher/Etc..
Shower, Single StalL................................................
Shower, Gang.................................... .:....................
Sink: Bar, Commercial, Residential Kitchen........................
Urinal, StaIlIWall:.:.. ;~................................................
Wash Basin/Lavatory, Single..................................
Toilet, Public Installation........................................
Toilet, Private.......................................................
Miscellaneous:
2 2
1
2
3
6
I 2
6
6
1
3
2
l/Head
I 2
2
2. 1
6
2 4
TOTAL FIXTURE UNITS
=
4-
2.
t.
z
'if
)(
CREDIT CALCULATION TABLE: Based on assessed value. If improvements occurred after annexation date in table,
~alculate credits separates.
I
Year
Annexed
Rate per $ 1 ,000
Assessed Value
1 979 or before
1980
1981
1982
1983
1984
1985
$3.46
3.38
3.32
3.21
3.06
2.92
2.73
Credit for Parcel or Land Only If Applicable
Improvement (if after annexation date)
Year
Annexed
1985
1986
1987
1988
1969
1990
1991
1993
Rate per $ 1 ,000 ----,\
Assessed Value
$2.46
, 2.14
1.77
1.37
0.97
0.61
0.44
0.15
=
3,-1-'" X $ /3,750
(Rate X Assessed Value)
X $
(Rate X Assessed Value)
=
-11..5~
..----
CREDIT TOTAL = $ -17.S-P
Inspections: 726.3769 L.....A.6...a ".,!.;.
Office: 726.3759 -..... ~-"
LOCATION OF PROPOSED ~ /), r: C ~2,d~..d.
ASSESSORS MAP: /18-02.'-; <-2/
RESIDENTIAL
PERMIT APPLICATION
.
LOT:
SPRINGFIELD
_JOB NUMBER 0/'1 /2/~
225 Fifth Street.
Springfield, Oregon 97477
" .
~~...u:;,C/ .bL"l-o..P
TAX LOT' 8 P, c9 0
BLOCK'
~H';?,oV'~
STAT~'
o,e
SUBDIVISION'
PHONE:
7~- ~.,....~
OWNER: -:-~ t,f- JA-C4Z.U/~
ADDRESS' 'Y'.v/ .,;:5;.."..,...,- .:5--_
CITY: .;::s::..:.,e........ac=;, ~:-~
ZIP:
e970 :/
DESCRIBE WORK:
/h"uhJ~n/l2e'D /I_..~ ~ ~~', _ .-=J/S--
NEW x
REMODEL
ADDITION
CONTRACTOR'S NAME J~
GENERAL: r::7....AA,.- ~a.i
"
PLUMBING'
MECHANICAl'
ELECTRICA~P-
I'
DEMOLISH
OTHER
ADDRESS
S;-,.z.? ~-"AJ
CONST,
. CONTRACTOR'
:,4tI.<::'7Z,
PHONE
7~,e:, -2/ 7/
"
;'
u
/?~,,/
'31<;JE
. OF BLDGS: \
OCCY GROUP:'P-~
. OF STORIES:--J.
WATER HEATER: ~
QUAD AREA:
- OFFICE USE -
LAND USE: \ \~()
. OF UNITS' . \
CONSTR. TYPE: \I - \\l
HEAT SOURCE: ~E?-
G
RANGE:
EXPIRES
//-/.I_Q/
" .
II'
FLOOD PLAIN'
ZONING CODE: \
. OF BDRMS:
~'\:/
~
SECONDARY HEAT:
SQUARE FOOTAGE\Q..& ~
To request an Inspection, you must call 726-3769. This Is a 24 hour recordIng. All 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.
D Temporary Electric
D
Site Inspection - To be made
after excavation, but prior to
setting forms.
D Underslab Plumbing!Electrical!
Mechanical - Prior to cover.
~ing - Atter trenches are
excavated.
D Masonry - Steel locatfon, bond
beams, grou.ting.
~undation - After forms are
erected but prior to concrete
PlaCemenl.q ~e.
D Underground Plumbing - Prior
to filling trench.
D
Underfloor Plumbing! Mechanical
- Prior to Insulation or decking.
D Post and Beam - Prior to floor
Insulation or decking.
o Floor Insulation - Prior to
decking, ,
,.-
~Sanitary Sewer - Prior to filling
trench.
~m Sewer - Prior 10 filling
~ ~~o~Ch.
~er Line - Prior to filling
~ -:;:~Ch.
o Rough Plumbing - Prior to
cover.
REQUIRED INSPECTIONS
D Rough Mechanical - Prior to
cove~ I
~U9h Electric~I" - Prior to ~
cover~ 'l-(\,~a.. '
D Electrical Service - Must be
approved to obtain permanent
electrical power.
D Fireplace - Prior to facing
materials and framing Insp.
~ming - Prior to cover.
~~e.
D Wall/Ceiling Insulation - Prior to
cover.
D Drywall - Prior to taping.
D Wood Stove - After Installation.
D Insert - After fireplace approval
and Installation of unit. .
.
~cut & Approach':.... Arter.
forms are erected but prior to
placement of concrete. -
~ ,'.
ewalk & Driveway - After
excavation is com.pl,ete, forms
and sub.base materIal In place.
D
Fence - When completed.
D
Street Trees - When all required
trees are planted.
D Final Plumbing - When all
plumbing work Is complet,e.
'~
lLJ ~ri~.al Electrical - When all
electrical work is complete.
D Final Mechanical - When all
mechanical work Is complete.
l2r!:0al Building - When all
required Inspections have been
approved and building is
comPleted,~~<2.....
DOthcr
MOBILE HOME INSPECTIONS
r:Y~ing and Set. Up - When all
I,.LJ blocking Is complete,
~ing Connections - When
home has been connected to
water and sewer.
~trlcalconnoCtion - When
blocking, set.up, and plumbing
inspections ha~.9 been approved
and the..home is connected to
the servIce panel.
~, - After all required
Inspections are approved and
porches, skirting, decks, and
venting have been Installed.
. ' ,. ~ THE PROPOSED WORK IN THE
., t"
.~. h
Lot faces l~ Sa t bac ks
lol sq, ftg, I PL. ' HSE . GAR ',ACC I HISTORICAL DISTRICT, OR ON
_ Interior IN 'lj't I THE HISTORICAL REGISTER?
Lot coverage Corner If yes, this application must ba signed
0 Is I and approved by the Historical
Topography Panhandle Iw ~ I Coordinator prior to permit Issuance.
Total height ,~- Cul.de.sac
IE 6 I APPROVED:
BUILDING PERMIT
\~
-p,~
ITEM
X $/SQ, FT,
VAlU~,
L.\{) .Wj
"\ ~1
Main
\~_\O
Garage
Carport
~\ ~('\
Total valU),J
~. OOD
~l
('\ :1"5'\ (deS .~
I 'iD5'''r 3. ~a
(A) :r~ ~~
Building Permit Fee
State Surcharge
Total Fee
SYSTEMS DEVELOPMENT CHARGE (SDC)
, .J,a.z.? 01
(B)
PLUMBING PERMIT
ITEM
I
Fixtures
FEE
Residential Bath(s)
Sanlt,a"ry Sewer
Water
N'
FT,
FT,
2.6~'
'L6~
?6 -
Storm Sewer
FT,
Mobile Home
Plumbing Permit
~
<2.U)+- ~.'5
R\~
Stato Surcharge
Total Charge
(e)
MECHANICAL PERMIT
Furnace
Exhaust Hood
Vent Fan
N'
Wood Stovellnsert/Flreplace Unit
Dryer Vent
Mechanicai Permit
Issuance
State Surcharge
Total Permit
(D)
I:2Y
\ ct>. qQ.-
~o.~
~ "-.1. 5. 'L~
. \ "\. 05
\~.~
MISCELLANEOUS PERMITS
Mobile Home
State Issuance
State SurchR
Sidewalk h\ . t
Curbcut ?~
It
It
Demolition
State Surcharge
Total Miscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding electrical) ~'4.l. \~
(A, B, C, D. and E Combined)
,
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 Clly 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.
Plan Check Fep'
Date Paid:
Receipt Number'
Recr.rBy:-~
~i!.".
Plans l1e*ewed By
Date'
Systems Development Charge Is due on all undeveloped
properties within the City limits which are b~lng Improved.
ADDITIONAL COMMENTS
/979
/37Sn.o-Q
Anl1;c=,,( !
A.f-r!
By signature, I state and agree, that I have carefully examined
the completed appllcallon 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 lhe 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.
1 further certify that only contraclors and employees who
are In compliance wllh 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 rei of pi will remain
on the site at all tlm~r?tr on:
~natdJ _
Date ,A?-/~- ~ '
/
VALIDATION:
RECEIPT NUMBER
DATE PAIf'l
/~'5o C;
<&/ t' 2-/)'~
2. $ ~ ~, C;-o
,4(~,
AMOUNT RECElvcn,
RECEIVED BY