HomeMy WebLinkAboutPermit Building 2005-4-7
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. 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
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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
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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
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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
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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