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Home My WebLink AboutPermit Building 2005-4-7 "_. $~~ING~j."""'.. ....~. '.......... '........ ,~,ajj . ~.,. . CITY OF SPRINGFIELD' Building/Combination Permit ; Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line PERMIT NO: COM2005-00357 ISSUED: 04/07/2005 APPLIED: 03/30/2005 EXPIRES: 10/07/2005 VALUE: $ 243,744.00 SITE ADDRESS: 6008 Orchid Ln ASSESSOR'S PARCEL NO.: JASPER MEADWS 2 AD Springfield TYPE OF WORK: Single Family Residence TYPE OF USE: New PROJECT DESCRIPTION: Jasper Meadows 2nd add lot 105 - Single Family Residence. Owner: HAYDEN ENTERPRISES Address: 2622 SW GLACIER PL #110 REDMOND OR 97756 Residential Phone Number: 541-461-5091 REQUIRED PARKING 2 I CONTRACTOR INFORMATION I Contractor Type General Electrical Mechanical Plumbing Contractor License Expiration Date HAYDEN ENTERPRISES ;, -":,~[X'-l('\~,!' 92~0~r'''' I",^, ~E'C1U\O~m'9~~~ THORNTON ELECTRIC INC ,I' ..,' ".J 116329 \' the OrEWlO1ijbo6Y PACIFIC AIR COMFORT INC ",' ;I)';ctl~l~.:ii' '-It}?j~7Th~~e rules OOt2Si~biRft~ JET HEATING INC , n _,.' <:) Qi::':Ln()~9.1cl1 0 through O~j:i~ BUlLDIN(i;;llNlF~1)l~w=tin copies OT UI~ I Ult:i,;) L, \'\'Ing the CE:lIIl~. (Note: the te'~~ho~e ca nJ ItTWilcatiOn # of Stor~~mber for the Orego.T' II'L lze: Height of Struct~nter is 1.~i~2. 1st Floor: Type of Heat: Forced Air Gas Sq Ft 2nd Floor: Water Type: Gas Sq Ft Basement: Range Type: Electric' Sq Ft Garage/Carport Energy Path: Path ISq Ft Other: Sprinkled Building: n/a Occupant Load: # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: M # of Bedrooms: 1 R-3 VB 4 I DEVELOPMENT INFORMATION I Front yard Setback: Side 1 Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: 22.20 15.90 19.90 15.90 0.00 Overlay Dist: Total: # Street 1fte$~~:: 3 Handicapped: P~y'ed Drl'f~I~~RMIT SHALL ~p'ME IF Com'pact: % ofLotAl1rer.age. .dO' THE WURK nuruZED UNDER HIS PERMIT IS NOT C?~~~E_N0Fn m~ Ie: lH~ M"::'.:'N[~ fOn I PUBLIC IMPKO\xEMEN.1JS1PERIOD. Sidewalk Type: Subdivision Not Accepted Street Improvements: Storm Sewer Available: Special Instruction: Fullv Improved Yes Downspouts/Drains: Phone 541-501-4332 541-686-4151 541-672-9510 503-363-2334 7,066 1,008 1,006 . 480 424 Curbside 5' Curb and Gutter Notes: No hook-up to City Infrastructure until Public Improvements accepted by the City; storm drainage piped to curb face 4/5/2005 CAS Page 1 of 4 --~~,:.~.~.'~~, '",. ", i., LM.... "". ~..' Status Issued CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2005-00357 ISSUED: 04/07/2005 APPLIED: 03/30/2005 EXPIRES: 10/07/2005 VALUE: $ 243,744.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line I Valuation Descriotion I Dwellinf!s Garaf!e Tvpe of Construction V Wood Frame Garaf!e $ Per Sq Ft or multiplier $96.00 $25.00 Square Footage or Bid Amount 2,414.00 480.00 Value Date Calculated Description Total Value of Project $231,744.00 $12,000.00 $243,744.00 03/30/2005 03/30/2005 ~ Fee Description Amount Paid Date Paid Receipt Number Plan Review Same As $100.00 3/30/05 2200500000000000360 -Mechanical Issuance Fee- $10.00 4/7/05 1200500000000000430 + 10% Administrative Fee $159.17 4/7/05 1200500000000000430 + 7% State Surcharge $111.42 4/7/05 1200500000000000430 3 Baths One & Two Family $306.00 4/7/05 1200500000000000430 Addressing Assignment $31.00 4/7/05 1200500000000000430 Building Permit $1,033.65 4/7/05 1200500000000000430 Curbcut Permit $80.00 4/7/05 1200500000000000430 Dryer Vent $6.00 4/7/05 1200500000000000430 Exhaust Hoods $9.00 4/7/05 1200500000000000430 Furnace - up to 100,000 btu $12.00 4/7/05 1200500000000000430 Gas Fireplace $15.00 4/7/05 1200500000000000430 Gas Outlets 1-4 $4.00 4/7/05 1200500000000000430 Plan Review Major - Planning $103.00 4/7/05 1200500000000000430 PW Disc - 2nd Permit (Street) $-30.00 4/7/05 1200500000000000430 Residence Wiring 1000 Sq Ft $106.00 4/7/05 1200500000000000430 Residence Wiring Ea Addtl 500 $76.00 4/7/05 1200500000000000430 Sanitary Sewer - Improvement $457.00 4/7/05 1200500000000000430 Sanitary Sewer - Reimbursement $601.00 4/7/05 1200500000000000430 SDC MWMC Administration $10.00 4/7/05 1200500000000000430 SDC MWMC Improvement $865.31 4/7/05 1200500000000000430 SDC MWMC Reimbursement $82.03 4/7/05 1200500000000000430 SDC Sanitary/Storm Admin $123.64 4/7/05 1200500000000000430 SDC Transpo Admin $63.65 4/7/05 1200500000000000430 SDC Transpo Improvement $772.49 4/7/05 1200500000000000430 SDC Transpo Reimbursement $175.13 4/7/05 1200500000000000430 Sidewalk Permit $80.00 4/7/05 1200500000000000430 Storm Drainage Impervious Area $782.91 4/7/05 1200500000000000430 Vent Fan $24.00 4/7/05 1200500000000000430 Willamalane Single Family $1,000.00 4/7/05 1200500000000000430 Total Amount Paid $7,169.40 Paf!e 2 of 4 Status Issued CITY OF SPRINGFIELD Building/Combination Permi( PERMIT NO: COM2005-00357 ISSUED: 04/07/2005 APPLIED: 03/30/2005 EXPIRES: 10/07/2005 VALUE: $ 243,744.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line' Initial Review Planninl! Review Public Works Review 04/04/2005 04/04/2005 04/04/2005 I Plan Reviews' 04/04/2005 APP 04/0612005 APP 04/05/2005 APP SKG TAJ CAS No hook-up to City Infrastructure until Public Improvements accepted by the City; storm drainage piped to curb face 4/5/2005 CAS Same as 6011 Orchid Structural Review 04/04/2005 04/06/2005 APP RJB 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. l..Reouire~nsDections I Erosion/Grading Inspection: Prior to ground disturbance and after erosion measures are installed. Sidewalk - Curbside: After forms are erected but prior to placement of concrete. Curbcut - Standard: After forms are erected but prior to placement of concrete. Vfer Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing and/or foundation inspection. Footing: After trenches are excavated. Foundation: After forms are erected but prior to concrete placement. Post and Beam: Prior to floor insulation or decking. Floor Insulation: Prior to decking. Shear Wall Nailing: Before covering sheathing with finish materials. Framing Inspection: Prior to cover and after all rough in inspections have been approved. Wall Insulation: Prior to cover. Ceiling Insulation: Prior to cover. Drywall: Prior to taping. Final Building: After all required inspections have been requested and approved and the building is complete. Perimeter Foundation Drains: After gravel and filter cloth is installed but prior to backfill. Rough Plumbing: Prior to cover and including required testing. Water Line: Prior to filling trench and including required testing. Sanitary Sewer Line: Prior to filling trench and including required testing. Storm Sewer Line: Prior to filling trench. Final Plumbing: When all plumbing work is complete. Vnderfloor Mechanical. Prior to insulation or decking and including required testing. Rough Gas: After line is installed and required testing and capped if not attached to an appliance. Gas Service: After line is installed and line has been connected to a minimum of one appliance including required testing. Presure test done at this point. Rough Mechanical: Prior to Cover Final Gas: When all gas work is complete. Final Mechanical: When all mechanical work is complete. Rough Electric: Prior to Cover Electric Service: Approval required prior to utility company energizing service. Final Electric: When all electrical work is complete. Pal!e 3 of 4 '_SP.~J,NG.~,'~','" "~"",.',,' '.,.,." Wii:J.t~, I" .,L"" , ,_ ".,". .r ".""".,.~.-..,".,~",,,,. . . .," .,.~. ' ; Status Issued CITY OF SPRINGFIELD - Building/Combination Permit PERMIT NO: COM2005-00357 ISSUED: 04/07/2005 APPLIED: 03/30/2005 EXPIRES: 10/07/2005 VALUE: $ 243,744.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line 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 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 701.005 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 Pa2e 4 of 4 Notice to Permit Applicant Soils stabilization requir~d for subdivision sites Name of Owner \.,a-\o.L\cloll" . Permit: ~56.?b'1 Address ofproject: ~o.tt>~ lQwhir! TaALot: \{)~ Tax Map: Subdivision ~~\ .~~ M-M1icL\())-\ The building site at the above address is located on property that has soils prone to shrink-swell or other potential movement. Excavations, placement of fill materials and drainage for this site must be done under the direct supervision of a properly licensed Professional Engineer or Architect to verify the stability of the resulting building pad and the site. The owner, or the owner's qualified agent, is responsible to obtain the services of the appropriate professional engineer or architect (design professional). The design professional shall provide direction for the stabilization methods to be used for the building pad (and surrounding site, when site stabilization is also necessary). The geotechnical report, which was prepared for this subdivision, may be utilized to provide appropriate guidance for the methods of stabilization and required compaction for the specific site. The engineer or architect shall prepare a report to be submitted to the City stating how the soil stabilization is being accomplished, including requireinents not yet completed (if any). A signed and stamped report from the engineer or architect must be received and avproved hv this office before footine or foundation insvection avvroval will beeranted hv the Citv Buildine Insvector. ACKNOWLEDGEMENT: The undersigned acknowledges the forgoing requirements for soil stabilization, including excavation, fill, soil compaction and drainage, as provided in the geotechnical report for the subdivision. The stabilization will be accomplished under the direction of a licensed professional engineer or architect as noted above. Signature .::;)-~ Name ~)~~' ~-~ Date Lf/r-/or I Affiliation to owner CITY OF SP~GFIELD SYSTEMS DEVELOPMENT JOURNAL OR JOB NUMBER: COM2005-00357 NAME OR COMPANY: Hayden Homes LOCATION: 6008 Orchid Ln TAX LOT NUMBER: Jasper Meadows 2nd Add Lot 105 DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE. NEW DWELLING UNITS 1 BUILDING SIZE (SF: 2014 1. STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. x COST PER S.F. CHARGE 1 2525.50 $0.310 = I $782.91 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S.F.' x r COST PER S.F. 'I x I DISCOUNT RATE I I I 0.00 I $0.310 I 50% I = I ITEM 1 TOTAL - STORM DRAINAGE SDC '$782.91 I 2. SANITARY SEWER - CITY, A. REIMBURSEMENT COST: I NUMBER OF DFU's I x I 25, B. IMPROVEMENT COST: I NUMBER OF DFU's I x I 25 I .IRKSHEET J \ LOT SIZE (SF): 7066 r:n ~ c:l o u ~ ~ t-< r:n ...... o ~ DISCOUNT $0.00 $782.91 I 107~ ,~. r COST PER DFU I $24.04 $601.00 1091 $18.28 $457.00 1092 ITEM 2 TOTAL - CITY SANITARY SEWER SDC = , $1,058.00 3. TRANSPORTATION A. REIMBURSEMENT COST: I ADTTRIPRATE x NUMBER OF UNITS x I COST PER TRIP x I NEW TRIP FACTOR I 9.57 1 I $18.30 I 1.00 $175.13 1093 B. IMPROVEMENT COST: I ADT TRIP RATE x I NUMBER OF UNITS x COST PER TRIP x INEW TRIP FACTOR' I 9.57 I 1 $80.72 I 1.00 $772.49 1094 ITEM 3 TOTAL - TRANSPORTATION SDC = , $947.62 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: NUMBER OF FEU's I x ICOST PER FEU 1 I I $82.03 = $82.03 1054 B. IMPROVEMENT COST: INUMBER OF FEU's x ICOST PER FEU I 1 I $865.31 = $865.31 1055 MWMC CREDIT IF APPLICABLE (SEE REVERSE) $0.00 I 1054 MWMC ADMINISTRATIVE FEE $10.00 1056 ITEM 4 TOTAL - MWMC SANITARY SEWER SDC =, $957.34 SUBTOTAL (ADD ITEMS 1, 2,3, & 4) =, $3,745.87 5. ADMINISTRATIVE FEE: I SUBTOTAL x ADM. FEE RATE I $3,745.87 5% TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: CHARGE $187.29 123.64 $63.65 11079 , 1078 Cheryl Slaymaker 4/5/2005 TOTAL SDC CHARGES =, $3,933.16 PREPARED BY DATE DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVAlENT = DRAINAGE FIXTURE UNITS (NOTE: FOR REMODELS, CALCULATE ONLY THE NET ADDITIONAL FIXTURES) NO. OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUIVALENT UNITS BATHTUB 2 0 3 = 6 DRINKlNG FOUNTAIN 0 0 1 = 0 FLOOR DRAIN 0 0 3 = 0 INTERCEPTORS FOR GREASE 1 OIL 1 SOLIDS 1 ETC. 0 0 3 = 0 INTERCEPTORS FOR SAND 1 AUTO WASH 1 ETC. 0 0 6 = 0 LAUNDRY TUB 0 0 2 = 0 ICLOTHESWASHER/MOP SINK 1 0 3 = 3 ICLOTHESWASHER-30RMORE(EA) 0 0 6 = 0 IMOBILE HOME PARK TRAP (l PER TRAILER) 0 0 12 = 0 RECEPTOR FOR REFRIG 1 WATER STATION 1 ETC. 0 0 1 = 0 RECEPTOR FOR COM. SINK 1 DISHWASHER 1 ETC. 0 0 3 = 0 ISHOWER, SINGLE STALL 0 0 2 = 0 I SHOWER, GANG (NUMBER OF HEADS) 0 0 2 = 0 I SINK: COMMERCIALIRESIDENTIAL KITCHEN 1 0 3 = 3 I SINK: COMMERCIAL BAR 0 0 2 = 0 I SINK: WASH BASINIDOUBLE LAVATORY 1 0 2 = 2 ISINK: SINGLE LA V ATORYIRESIDENTIAL BAR 2 0 1 = 2 URINAL, STALL/WALL 0 0 5 = 0 TOILET, PUBLIC INSTALLATION 0 0 6 = 0 TOILET, PRIVATE INSTALLATION 3 0 3 = 9 MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 25 *EDU (Equivalent Dwelling Unit) is a discharge equivalent to a single family dwelling unit (20 DFD's) se~~.1~;? gal~~~ per day MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 CREDIT RATE/$l,OOO ASSESSED VALUE $5.29 $5.29 $5.19 $5.12 $4.98 $4.80 $4.63 $4.40 $4.07 $3.67 $3.22 $2.73 $2.25 $1.80 $1.59 $1.45 $1.25 $1.09 $0.92 $0.72 $0.48 $0.28 $0.09 $0.05 IS LAND ELGIDLE FOR ANNEXATION CREDIT? (Enter ] for Yes, 2 for No) IS IMPROVEMENT ELGIDLE FOR ANNEX. CREDIT? (Enter 1 for Yes, 2 for No) BASE YEAR 2 2 ]979 CREDIT FOR LAND (IF APPLICABLE) VALUE 11000 CREDIT RATE $0.00 x $5.29 = I $0.00 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALUE 11000 CREDIT RATE $0.00 x $5.29 = , o TOTAL MWMC CREDIT = $0.00 , 225 Fifth Street, . Springfield, Oregon 97477 541-726-3759 Phone GUy of Springfield Official Receipt '\:_:{f,/ ''''''elopment Services Department Public Works Department Job/Journal Number COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 OOM2005-00357 COM2005-00357 COM2005-00357 CbM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 COM2005-00357 Payments: Type of Payment CreditCard .. 4/7/2005 RECEIPT #: 1200500000000000430 Date: 04/07/2005 Description Addressing Assignment Willamalane Single Family Residence Wiring 1000 Sq Ft Residence Wiring Ea Addtl 500 Sidewalk Permit Curbcut Permit PW Disc - 2nd Permit (Street) Storm Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Transpo Reimbursement SDC Transpo Improvement SDC MWMC Reimbursement SDC MWMC Improvement SDC MWMC Administration SDC Sanitary/Storm Admin SDC Transpo Admin Building Permit 3 Baths One & Two Family Furnace - up to 100,000 btu Vent Fan Exhaust Hoods Dryer Vent Gas Outlets 1-4 Gas Fireplace -Mechanical Issuance Fee- + 7% State Surcharge + 10% Administrative Fee Plan Review Major - Planning Paid By HAYDEN HOMES Item Total: Check Number Authorization Received By Batch Number Number How Received djb 067368 In Person Payment Total: Page 1 of 1 2:16:32PM Amount Due 31.00 1,000.00 106.00 76.00 80.00 80.00 (30.00) 782.91 601.00 457.00 175.13 772.49 82.03 865.31 10.00 123.64 63.65 1,033.65 306.00 12.00 24.00 9.00 6.00 4.00 15.00 10.00 111.42 159.17 103.00 $7,069.40 Amount Paid $7,069.40 $7,069.40 1. j~!~p]~fi2~glfJfij!1fE0tiJ}; ~ {)/YJ.,f/f Lvt ~ Mg:'f ::lfSRlPT.JON ~P" ~J ~)T 'SlcYnQ(jtaJJfh~JLd-/~ JOB DESCRIPTION ~ ,rhv.~ ~~JIv /4;f~~ (; r' Permits are non-transferable and expire if work is not started within 180 days of issuance or if work is Suspended for 180 days. 225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 · FAX~ (541)726-3689 ",'" ELECTRICALPER.J\IIIT APPLICATION ' :., ~O\0C,~~,~ City Job Number r: t:;:- &;0 5 r"I , Date ~\"'~ ~00? .I .J -r- ' 0:-,\0 ",0 '\ '0' - 3. t:;;QQMiFiErE;:lfEEs~S~1iE!-Y:;i:V)' ::ii,',\..::;';':';".I::,y:C: ;, >"';:'.~c.;:..-O.,;<.:;;, S". _.<.'. "~,~",>;,::"::"h..:.-":;.,,,<j;'S!f/iJXi!.i'd;\,.:;.,;f..,::;,,.,::t~>0:::L> ,,': '::,:,:k,:~:~.i~ '0' ~v _t~I;~1!!L~1i,j A. Service Included 1000 sq. ft. or less Each additional 500 sq. ft. or portion thereof Each Manufact'd Home or Modular Dwelling Service or Feeder f $106.00 1{)(Pt cD '--:ft' e€J ~ $ 19.00 I If' $50.00 B. 2. Electrical Contractor 77/t?1f4 .17(J I~ J ate:} /(t 200 Amps or less -,..-. _', 201 Amps to 400 Amps Address I? (J, t?&;r wL/ I...) -' (~': . J,,o:'40aJAmBS to 600 Amps ,- ., "Il;"'a_' -<:;!.j fila I{' ~ 1,'(;"/0/7:" ~6'dr~~f'bto ~'6~Rs Phone 9)~ -~~.:~ ~52_0~~elv1!r 11W8}}Hps~~oS YOU to , . aU r{)fa~@1ff1}, tJrlil.jles fI Utility Calling thrnay Obtai aUgh are Set fo nUrnb e Cen '2 " /7 r' er r. c: Supervisor License Number .-.J<:../ ...) Or the' S' ffl l,'enter i e90n Vt'.. e teleph ~ s in~!Jl~!~81l?nO~elocation . 200 AmPs~fili~J. CCltion' 201 Amps to 400 Amps 401 Amps to 600 Amps , Over 600 D. City Eie.~ U $ 63.00 $ 75.00 $125.00 $163.00 $375.00 $ 50.00 Expiration Date 10/ 1- 0 (0 Constr. Contr. Number I I/e? _~d? / $ 50.00 $ 69.00 $100.00 Expiration Date /('l~ 1- () b Signature of Supervising Electrician .~~/,Jkd_~) Owne" Nam" ~ ~ cl\ Adm" ~)'d)K - M3 City "'" - \ Ph:e-!l!l..fJ New Alteration or Extension Per Panel One Circuit Each Additional Circuit or with Service or Feeder Permit $ 43.00 $ 3.00 E. t (1S' ~.' -'P~rilp or irrigation $ 50.00 - -r rilS @igN6~I&e:tliht@gP!RE IF THE IiIIO:=1:< $ 50.00 i\Ull-:jJ~i~~~JErl&~~Iidei)tii1H1;\IIiT IS I\;cn $ 25.00 CrL','IJlI\t, :.-I\I".~::J1'1. n '=l I~il ~:' ,II 'VII',.I c'O cO I) $ 4500 ' , 'L'lml=':t1'lergYt\...omm~~la ' L 1 I ~ . '~I\:\I 1 bO !)pY c;:~'JOD 'Minimum "EI'ectrtcl Permit Inspection Fee is $45.00 + Surcharges The installation is being made on property I own which is not intended for sale, lease or rent. Owners Signature: 4. /~Zl ()D 12 J ':]-1./ JI?lJD ~ 2.1 2 ~ 'Ii 7% State Surcharge 10% Administrative Fee Inspection Request: 726-3769 TOTAL Shared Drive(T:)/Building FOIms/Electrical Pennit Application I-03.doc