HomeMy WebLinkAboutSpecial Inspection Application 1994-12-2
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HOUSING INSPECTION APPLICATIPN
CITY OF SPRINGFIELD
BUILDING DIVISION
================================================================================
DATE:
\2.-12..1 <:14
JOB NUMBER: '71'JG63
ADDRESS OF INSPECTION: ~Z.<75 .!::::lV\<;i20w ~ PJ"lfA.U
,
OYNER: ?{eAiM,rl (,1\A~fw.c...~~
OVNER'S ADDRESS: SoS~e'\ ~ ~4 S:>['n/
PHONE NUMBER: 7<f<..f-q~'-I
,
APPLICANT: IAMA(.L 16~ ,
APPLICANT'S ADDRESS: ;(D(~E" tireJ..- .t.lcr
,.
~f.c~
74<4 - ']7..04
FOR ACCESS TO PROPERTY - TELEPHONE NUMBER:
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A $35.00 INSPECTION FEE IS REQUIRED AT THE TIME OF APPLICATION
THIS APP CATION FORM MUST BE IGNED BY THE OIlNER OF THE PROPERTY TO BE
INSPECT .
FOR 0 CE USE ONLY
--------------------------------------------------------------------------~-----
DATE PAID: (Z - L- .- q c.! RECEIPT NUMBER: /571) L/~
DATE OF INSPECTION:
DATE OF CERTIFICATE OF COMPLIANCE:
DATE OF REPORT:
COMMENTS: /_A~~;UJ~
-.E.~ ~A-r/(Z.60
~~A{)SJii!h...) C ~~
S77tJIUh4 J. htwS.e /S ll;U ~
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Job No. C}4l &li3
SYSTEMS DEVELOPMENT CHARGE
J.J JlI. rl\0\^ WORKSHEET
NAM"yaLM"'- Jb~ -II PHON,,-.944.~
ADDRESS: ~~[)S L.lfu9t; 11 ~ STATE:~ ZIP..1::MJJ..
LOCATION OF Ii'ROPOSED BUILDING SITE: _\ '- I
Street Address if Known: \ 0 \ n ~ \ ~-U \~
Platt Name: \'\. \~ ~ Tax Lot Number: \\O~~~~ DC1(])
1. DEVELOPMENT TYPE (Check appropriate dwelling(s). sac Calculations and dwelling type
definitions are on Ihe back.>
A. Sin"le Familv - Detached
---L Single Family home
NO OF UNITS
B. Sin"le Familv - Attached
NO OF UNITS
C. Multi-Familv Aoartment
NO OF UNITS
D. Manufactured Home Park
NO OF UNITS
Manufactured home not in a park
l X $400 PER UNIT _= $ 4rf)(:V
X $370 PER UNIT =
.$
X $277 PER UNIT =
$
X $280 PER UNIT =
$
WPRD SDC
2. SDC CREDIT (If applicable) SDC-payer must furnish proof of WPRD Credit
approval. See SDC Credit Worksheet
3. TOTAL WPRD NET SDC ASSESSED (If SDC reduced for Credit)
$4ff).cD
$16
$ 4tO~
~~L~e)
r:... ,,( c........:....,.,..(;....l.....
~f \
l~
Date
e,
e
zoni~g, and does not require specific land use
approval.
225 FIFTH STREET Zoning LAde.-
~~~~g~~:fREg~~~~ 9~;~~:f~~"2- t-:t1{'
OFFICE: 726-3759 AUlhorizod Signature
1. LOCATJ~~~~~~ALLATION
-'" I r . ' ,k
\ rJt)?'A~~~lJ)0
L~~E~TR)~ QQ0rnnOrJ-
..J
Permits are non-transferable and expire
if work is not started within 180' days
of issuance or if. work is suspenaed for
180 days.
2..' CONTRACTOR INSTALLATION ONLY
Electrical Contractor ~~~~
'5 <p (;:), ~\)~ tw
Phone b f'~ - ~ <.pr;
Number (, 7 ~-.s
Expiration Date /tJ-(- 9-5'
Address
City;:? -r'^ OL.
Supervisor License
Cons t r Con t L NumberH 17 () d
Expiration Date 1-)..3-(/L
Signature of Supervising Electrician
r\ I . I '-.
;;y..Ll.f.- Ie........
Owners NarrH.(JIJilO ~~)J
Address..q~ ~-*q ()
Ci ty 9D~ Phonel44.QllJ]
~}NSTALLATION
The installation is being made on
property I own which is not intended
for sale, lease or rent.
.
Owners Sirrnature:
------------------------71-------------
DATE: . c!) ./. i<; .
ItECEII'T /I: \.JJ ,'\ \n....1l
RECEIVED BY: c.J\~ ~.
Ci ty Job Number
~ ~OMPLETE FEE SCHEDULE BELOY
ELECTRICAL PERMIT APPLICATION
q4\81 o.~
A.
New Residential-Single or
Multi-Family per dwelling
Service Included:
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereof
Each Manuf'd Home or
Modular Dwelling
Service or Feeder
B.
Services or Feeders
Installation, Alterations
or Relocation:
200 amps or less
201 amps to 400 amps
401 amps to 600 amps
601 amps to 1000 amps
Over 1000 amps/volts
Reconnect Only ~
uni t.
Items
Cost
Sum
$ 85.00
$ 15.00
S 40.00
$ 50.00
$ 60.00
$100.00
$130.00
$300.00
$ 40.00
.
-W-
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 volts
D.
Branch Circuits
$ 40.00.
$ 55.00' "
$ 80.00
see UB" a~
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 with Service
or Feeder Permit
E.
5. SUBTOTAL OF ABOVE
57. S ta te SUI:charge
37. Administrative Fee
TOTAL
$ 35.00
$ 2.00
no t included)
$ 40.00
$ 40.00
$ 20.00
S 36.00
4{) .CD
tl,QU
I.UI
't<3. z.o
. ATIACHMENT B1
.B NO. . 9-f/'?c'.3
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE
. WORKSHEET
(COMMERCIAL & RESIDENTIAL)
NAME OR COMPANY:
LOCATION: (0/0
DEVELOPMENT TYPE'
BUILDING SIZE:
~j?~
-1J~4rI.-d~
, i
5',1=1) I~~.-...)
- ,.
LOT SIll:'
SQ. Ft.
1. STORM ORATNAGF
,
IMPERVIOUS SQ. FT. 42+1 X $0.209 PER SQ. FT. ~-0
2. SAMlIARY SFWFR-r.TTY
NO. OF PFU'S . 2S'" X $43.26 PER PFU "~F0
(See Reverse)
3. TRANSPORTATION
NO OF UNITS X TRIP RATE X COST PER TRIP
I X /.01 X $436.19
X X $436.19
-~
(~~
$
x
X $436.19
$
SUBTOTAL (ADD ITEMS 1.2. & 3) $ Uo9.o S
4. ~ANTTARY SFWFR-HWMC
NO. OF PFU'S 25 x $17.19 PER PFU + $10 HWMC ADMIN.FEE $ 4-39.15
(Use PFU Total From Item 2 Above)
MWMC CREDIT IF APPLICABLE (SEE REVERSE)
. . . . . . . '. IQIAI .MWMr c:.oc
SUBTOTAl (ADD ITEMS 1.2.3 & 4)
$ S-/.'8"
V3T1.r~ ')
- -
$ .2'19". f 3
5. bOMTNTSTATTVF FFFS
. BASiCHARGE SU OTAl ABOVE) X .05
/.
~~ .." Date:
/ Ma y rnig. \P.E. )
SO rd; nathc/
<:fl~9. 40
/-/3-?5-
IQIAI SOC
$ 29'3".7 r
B2 . SDC .
FIXTURE U'NIT CALCUL_ON TABLE: Number olNew FiX. X Unil Equivalenl = Fixture Units
(NOTE: For remodels. calculate only. M.EI additional lixlures)
NUMBER OF UNIT FIXTURE
FIXTURE TYPE NEW FIXTURES EOUIVALENT UNITS
3
c.,
2
1
2
3
6
2
6
6
1
3
2
11Head
2
2
1
6
4
",
Balhlub..................................................................... .
Drinking Founlain.. ............ ............. ............. .............
Floor Drain................................................................
Interceplors For GreaseIOiIISolidsIEtc.................
Interceplors For Sand/Aulo Wash/Elc..................
Laundry T ub/Clotheswasher...................................
Clotheswasher. 3 Or More.....................................
Mobile Home Park Trap (1 Per Trailerl..................
Receptor For RefrigeratorlWaler Station/Etc........
Receptor For Commercial Sink/Dishwasher/Etc..
Shower, Single Stall.................................................
Shower, Gang.................................;........................
Sink: Bar, Commercial, Residential Kitchen........................
Urinal, StalllWall..:....................................................
Wash BasinlLavatory, Single..................................
Toilet, Public Installation........................................
Toilet, Private.......................................................
Miscellaneous: I TANlrru'.s ~.NK
2
I
~
/
3
"3
/2
'?
2>-
TOTAL FiXTURE UNITS
=
Based on assessed value. If improvements occurred after annexation date in table.
CREDIT CALCULATION TABLE:
calculate credits separales.
r
Rate per $1,000
Assessed Value
Rate per $1,000
Assessed Value
Year
Annexed
Year
Annexed
$3.46
3.38
3.32
3.21
3.06
2.92
2.73
1985
1986
1987
1988
1989
1990
1991
1993
$2.46
2.14
1.77
1.37
0.97
0.61
0.44
0.15
1979 or before
1980
1981
1982
1983
1984
1985
3,7" X $ /1,Y'?O
(Rate X Assessed Value)
X $
(Rate X Assessed Value)
.<;-;. li' "l
Credit for !"arcel or Land Only If Applicable
=
..-
Impro.vement (if after annexation datel
=
CREDIT TOTAL = $ ~/_ 8' ~
RESIDENTIAL
PERMIT APPLICATION
Inspections: 726.3769
Office: 726.3759
LOT:
,
,
.
BLOCK'
OWNER: 'r4.l.nt'Sl _ V(JS IJ l.~
ADDRES~ ') ~ r, ~5TILPo b ~q
CITY' ~ 1 i\C"\~ Q rlf STATE:
DESCRIBE WORK:~f'i\ j n
NEW REMO~E~ ADDITION
.
JOBNUMBER~
225 Filth Street
Springfield, Oregon 97477
D~ID.)
SUBDIVISION'
. PHONE:
144. q?ffi
CONTRA~~ NAME 0
GENERAL. ~
PLUMBING: - I'
II
OTHER
IN'\ Zlp:_q-rt-U
Q cilii..oJ1l' 0
-
ADDRESS 4
o .ttJ\2D Sc.-.J.I\ (!() r
CON ST.
CONTRACTOR'
RloC\Dlo
EXPI~S r'J~~~~
~ \.0 .L\~ \~'L'lDI.01
MECHANIC.., .
ELECTRICAL:~9.\~ <::......
~ \ o('~ n I t,j
...: ---
QUAD AREA:
· OF BLDGS:
OCCY GROUP:
. OF STORIES:
\ Q K)\ ;')
\
\~~
G
WATER HEATER:
- OFFICE USE -
H\ \
LAND USE:
. OF UNITS: \ J
CONSTR. TYPE: -.1l.
HEAT SOURCE:
y",
RANG~'
FLOOD PLAIN:
ZONING CODE:
I nt'L--
. OF BDRMS'
SECONDARY HEAT:
SQUARE FOOTAGE:
To request an Inspection, you must call 726.3769. This Is a 24 hour recording. Alllnspeclions requested before 7:00 a.m. will be
made the same working day, Inspectlons requested after 7:00 a.m. will be made the following work day.
D Temporary Electric
D Site Inspection - To be made
atter excavation, but prior to
setting forms.
D Underalab Plumblng/Eleclrlcal/
Mechanical - Prior to cover.
~ootlng - After Irenches are
xcavated.
.
D Masonry - Steel location, bond
beams, grouting.
"D<:('Foundatlon - After forms are
~rected but prior to concrete
placement.
D Underground Plumbing - Prior
to filling trench.
D Underlloor Plumbing/Mechanical
- Prior to Insulation or decking.
M Post an~ Beam - Prior to floor
~Insulatlon or decking.
D Floor Insulation - Prior to
decking.
l'\:71 Sanllary Sewer - Prior to filling
~trench.
~ Storm Sewer - Prior to filling
~rench.
"1\71 Walar Line - Prior to filling
~trench.
D Rough Plumbing - Prior to
cover.
REQUIRED INSPECTIONS
D Rough Mochanlcal - Prior to
cover.
D 'RoughElectrlcal - Prior to
cover.
'1::"7'( Electrical ServIce - Must be
~ approved to obtain permanent
electrical power.
D Fireplace - Prior to facing
materials and framing Insp.
D Framing - Prior to cover.
D Wail/Ceiling Insulation - Prior 10
cover.
D Drywall - Prior to taping.
D Wood Slovo - After Installation.
D Insert - After fireplace approv!ll
and Installalion of unit.
D Curbcut & Approach - After
forms are erected but prior to
placemont of concrete.
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. t
D Final Plumbing - When all
plumbing w9rk is comp/et,e.
D Final Electrical - When all
electrical work Is complete.
D Final MechanIcal - When all
mechanical work Is complete.
~Flnal Building - When all
~ requIred Inspections have been
approved and building is
completed.
DOther
MOBILE HOME INSPECTIONS
D Blocking and Set.Up - When all
blocking is complete.
D PlumbIng Connections - When
home has been connected to
water and sewer.
D Electrical Connection - When
blocking, set.up. and plumbing
Inspections have been approved
and the home Is connected to
the service panel.
D Final - After all required
Inspections are approved and
porchos, skIrting, decks, and
venting have been Inslalled.
Lot faces
Lot Type
-Vlnterior
Corner
Lot sQ. fig.
Lot coverage
Topography Panhandle
Tot~~ ~yrU.p}- Cul.de.sac
, RY\'f"'-?'\
BUILDING PERMIT
ITEM
SO. FT.
X $/SO, FT.
Main
Garage
Carport
~lf\CJ)b.~
Total Value
Building Permit Fee
Stale Surcharge
'2.J' 3 + /.)'2..
Total Fee
(A)
(B)
PLUMBING PERMIT
ITEM
Fixtures
Residential Bath(s) N'
Sanitary Sewer FT. <'50 '
Water FT. <: '58 I
Storm Sewer FT. < 5" I
Mobile Home
Plumbing Permit
S S 7.7~ ~ "'7..>
tate urcharge ,;) ,.c-
Total Charge (C)
MECHANICAL PERMIT
Furnace
Exhaust Hood
Vent Fan
N'
Wood Stove/Insert/Fireplace Unit
Dryer Vent
Mechanical Permit
,Issuance
Stato Surcharge
Total Permit
(D)
MISCELLANEOUS PERMITS
Mobile Home
State Issuance
State Surcharge
Sidewalk ---- ft
Curbcut - ft
.r " ' :.: ~-~ '\1. .~ i
.S THE PROPOSED WORK IN THE.
....HISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTER?
If yes, this application musl be signed
and approved by Ihe Historical
Coordinator prior to permit issuance.
I P.L.
IN
Is
Iw
IE
Setbacks
HSE GAR'ACcl
I
I
I
I
-::? 2. lB~
3/0S./~
APPROVED:
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on the express condition that the said
conslructlon shall, in all respects, conform to the Ordinance
adopted by the Clty.of Springfield. including Ihe
Development Code, regulating the constructlon and use of
buildings, and may be suspended or revoked at any time
upon violation of any provisions of said ordinances,
Plan Check Fee'
Date Paid:
Receipt Number'
Received By:
Pla~m~~
Date
S/7.5'O
46JS'
sj.\S
SYSTEMS DEVELOPMENT CHARGE (SDC)
f293G,'lj'.
VALUE
"
~Sf'O~
./
FEE
2.';; ~ D
2<;""c
2500
'7C;.~.
~.O()
g/.()()
/
/
/
Systems Development Charge Is due on all undeveloped
properties within the City limlls which are being improved.
ADDITIONAL COMMENTS
D\a.,^-\'N\i'~_ \ Nt-, \~
\\ .
~+ -r' wi) +-7.JU1)~ I1jqq()
v:A n MX [)o TIh: \ C\ \ ~ r.C\
~~ dq: ~/.7 /S'_
~ ~~P/~..
~~>h~)bo~ ~/2::,J~J\ ~
7~ ~eCCJA/.l)k,77b" ~ 4~-;-
.:\~c.e,
By signature, I state and agree, that I have carefully examined
the completed' application and do hereby cerllfy that all
Information hereon Is true and correct, and I further certify
that any and all work performed shall be done in accorpance
with the Ordinanc~s 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 ()n this
project.
ensure that all required Inspections are
Demolition /
State Surcharge
/LAA.I #t?YhEz~ / ,I22s
Total Miscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, D, and E Combined)
VALIDATION:
\\onO
RECEIPT NUMBER
DATE PAID d . / . q. &=)
AMOUNT RECe:I~ ~ . 5'5-/.. & }E (llUc? C'(~T)
RECEIVED B~~
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INSPECTIONS 726-3769
",CITY OF SPRINGFIELD
225 North 5th Street
.
8USINESS 726-3753
'.
"
~J77
O~~DDRESS
L~J ~SlJ19 I
BUILDING MOVING PERMIT/8UILDING DIVISION
"
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NEW ADDRESS (Furnished by Building
~~~,,~*\ffi~
\l~ D3~UJ
Div. )'
.'
i
! tt~if\r~lbse LJ. $~sf -' !TI 00 t-
(,~g "Firm U Address Lics # Exp.
uVljJ\ '!\.'xx\(Y1D fjSS\J,.)? ~ ~D?A 4. '2.8.ql~
D~cr~ption ~f ~nten:ed'U~e CITY DESIGNATED JdB N~lBER
I ~l~l-- ~ ttuL 1J \ Q.~-cidmF" Qj 0\ 4\ 9i rO
~~"~~I\\n Q -\1)-~SJ"~rl'rtL I ffivfu()f\ I)~
D~s~~R#~il~\~~~C:Jt,~~,L fA rt ;'
,Square Footage ' Moving Lengt"ff f)l n Moving Width!1 3iight On Dolly{ /)01&1
Number Of Sections Being Move~" :iA.;.p.-:.. ~.!iCons~u~ion_ tJ rV.AL~Tlqti - - \ ;J
. /~ ;.:;.~ 1)')0.J.l.Y'~. 1{Q~,
NOTIFICATION OF ~lOVE: The Building Division "PLANS, FEES, AND CHARGES: Prior to l' eiv- /
will route copies of this application to all ing a permit to move a building to property
appropriate div~sions, departments and Agen- within the City, the applicant or his/her
! cies. HOtIEVER, the applicant must contact authorized representative must:
I property owners if trees are involved in the 1. Submit 2 copies of site or plot plan
proposed move. IN ADDITION, the applicant for new site.
must secure the approval of all appropriate 2. Submit'2 copies of foundation plan for
municipal, county and state authorities the 'relocated building.
should the move originate or terminate out- 3. Obtain a permit covering the new founda-
side the City of Springfield. tion, as well as all plumbinglmechanical
and electrical work relating to the re-
located building.
4. Pay Systems Development Chargc if appli-
cable.
SEWER CAP: Buildings movcd from within thc SEPTIC TANK REQUIRE~IENTS: Prior to moving,
City limits shall havc the scwer capped at owner shall have all sludge from the septic
the property linc and inspected one working tank, seepage pit or cesspool removed by a
day prior to the'move. If thc inspection person holding a sewage dispoa1 service li-
indicates that the sewer has not been prop- cense, and shall fill same with clean bar-
erly capped, the moving permit wif~~ run gravel or other material approved by the
revoked. /1. hnl1f:1A.y,2. lLf-D Director or his authorized representative.
I CERTIFY THADhe abovc itJor':ation is true and correct, that all re uired contac
bee ma t oribations obtained, that the move will begin at :tlh'c10ck am m ~
on,.~ .!:and will be completed by \0'.~o' c1ock@pm on .~. ~ . .
,and that no c~anges in thc route will be made without contacting the Buildin 1V1 10n. I
also certify that I havc;becn informed that NO PEro~IT WILL 8E ISSUED BEFORE WORKING DAYS
HAVE ELASPED. I further certify that my registration with the Buildcr's B rd, is in full
,force and effect as required by ORS 701.055 and 701.070,~nd that if exemp the basis is
noted hereon. Basis for Builder's Board Exemption: /f( /' ieJ;}' ..lfJA..u 1,
NAME6Yk>/1 r~#n1""'. SIGNATURE~} )_DATEiJ~
FOR OFFICE USE ONLY "-..-'
Type of Construction \J tv Occupancy Group R3
Phon.eq?!11
011ne
_~~. R~
I
.:.
"
'"
Zone \ f)Q...
Stories :;
Flood Plain
Living Units
\
Square Footage
VALUE.
Application fce $18.00 Datc Paid \ P- .CD
Permit fee $60.00 -- Date Paid l oDoO
~m.~,~~:;~re 6 @ .60~ ILD= q.ldl Amount ~~.~:~~. 9Yl1no~
!~ewer Cap...-'$10.00+: 49. State Surcharge -- Date Paid \\ V''11. A<.rAAJ~ ~rl~
I VP~lice Department : v.\~il~a~~l~~e Q~~;k and Recreation C.-Ra i nbc:,{, Water ~
,YFHe Departmentil . :~,L_ n.'. U'S~ vG'"roup W Cable
'~Northwest 'Gas"'! "vt'ime Transit District <--tanc County A & T
OTHER -- specify
Receipt Number
Receipt Number
ILnItQ\
\lo~'S I
.'
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.!
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BUILpING ,DIVISION REPDRT: 01.t).- qs
t,..!l ~ \~_\ol:)\AOf1!,QlIJ\\\ \Du... ffirr~ tJY1 /:/lq q5J
~ \.\~\1nrtJ\ll':HlJ'(\ ,~n\\\ 'fu .N\o,eA ~~\.;~\MQd~~
. J'
\ ~~~(\{\'~f'() Q t '1: ()() flIYl "<t in .J)lll.l\J1ili ~ ( ~
~ l>ffi~\ili1! r-l c q '.f'll '" 11'1\ ~~=L m rf\[. c\o::k,. \) tM<; -0f
\~'{\~i'\~ Sth~\f)~~af\~~)nMbt)-{\ \n()tf~ b2w ,.
}\ubffiilin:Q . BL2t\t'f)~Q(D~te /-Qf/:2
TRAFFIC DIVISION REPORT: \ , .
BUILDING MOVI~ERMIT
I. Applicant to furnish (except as indicated)
A. Old address for building
B. Legal Description
C. New address for building
(Building Div. will furnish)
D. Legal Description
E. Name, etc. of building owner
F. Name, etc. of moving firm
G. A description of intended use
H. A description of proposed route
I. A description of the building
II. Applicant to contact property owners if trees
involved, and secure authorizations from
other jurisdictions as necessary.
III. A site or plot plan, and foundation plan must
'besubmiiUedfor the new site (2 sets)
IV. Pl ans must also be submi tted for any other
work relating to the relocated building.
V. Fees & Charges:
A. Application fee due and payable at time
of application
B. Moving permit fees due and payable upon
permit issuance
C. FEES & CHARGES TO BE CALCULATED BY
BUILDING DIVISION STAFF
VI. FOR OFFICE USE ONLY
A. Plan check data collected
B. Copies of application to appropriate
divisions, departments and agencies "
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ENGINEERING DIVISION REPORT:
O\IJN~ I c.ol>l;-AAcra~ IS ~l"tlN..""I34.f::. E'Q~
I
o~ PUBLIc:. "RoPEg,~_
ADDITIONAL PROJECT INFORMATION:
l\ '
~ PERMIT VALIDATION
.
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;#0\10\6\
PERMIT CLERMfIXi.. ~
;2;z.,r, P LM.J f\ 1ft? /..e.
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~, SravJ.Ih'_ 4r"
j)c/;e-e t ~ ~z Tt).
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~ B" t..a.J3::. Date t//(,)/'i!S-
-- 0 f f
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D41'!M"'<" '0
By'f.Il'A\I....~e... Date 1/lo/'iS
I I
By
Date
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