HomeMy WebLinkAboutPermit Building 2010-9-16
www.cLspringfield.oLus
CITY OF SPRINGFIELD
Building I Residential Permit
PERMIT NO: COM2010-01026
IVR Number: 811000054208
PROJECT STATUS: Issued
ISSUED: 9/16/10
APPLIED: 7/30/10
EXPIRES: 3/26/2011
VALUE: $163,024.00
225 Fifth St
Springfield,OR 97477
Phone: 541.726.3753
Inspection Phone: 541.726.3769
Fax: 541.726.3676
permitcenter@ci.springfierd.or.us
SITE ADDRESS: 4120 STELLAR WAY Springfield
ASSESOR'S PARCEL NO: 1802061419200
SCOPE: SFD
WORK INVOLVED: NEW
TYPE OF STRUCTURE: RES
PROJECT DESCRIPTION:
Single family residence - Same as COM2010.00256 1033 S 41st - Related (child) record
811-SPR2010-00053
Phone Number: 541-606-5050
OWNER:
ADDRESS:
BRUCE WIECHERT CUSTOM HOMES INC
3073 SKYVIEW IN
EUGENE OR 97405
Contractor Type
General Contractor
CONTRACTOR INFORMATION
Contractor Name
BRUCE WIECHERT CUSTOM HOMES INC
L & E ELECTRIC INC
STEVEN R JOHNSON
COMFORT FLOW HEATING CO
L & E ELECTRIC INC
COMFORT FLOW HEATING CO
BRUCE WIECHERT CUSTOM HOMES INC
L & E ELECTRIC INC
STEVEN R JOHNSON
Lie Type
CCB
ELECTRICAL
CCB
CCB
ELECTRICAL
CCB
CCB
ELECTRICAL
CCB
Mechanical Contractor
EDWARD JAMES DENOUDEN-4174S
Electrical
Plumbing Contractor
~
Lie No Lic Exp Phone
101717 09/16/2012 541-686-9458
20-383C 07/01/2011 541-933-2598
65065 03/12/2012 541-342-3765
460 06/27/2011 541-726-0100
20-383C 07/01/2011 541-933-2598
460 06/27/2011 541-726-0100
101717 09/16/2012 541-686-9458
20-383C 07/01/2011 541-933-2598
65065 03/12/2012 541-342-3765
# of Units: 1
Construction Type
Occupancy Comments
Occupancy Type
Occupancy Type
Construction Type
# of Bedrooms:
Sprinkled Building:
Fire Alarms:
Energy Path:
Springfield Building Permit
BUilDING INFORMATION ~
Type VB
# of Stories:
Height of Structure:
Type of Heat: Forced Air Gas
Water Type: Gas
Range Type: electric
Hazmat: No
U
R-3.
Type VB
No
No Electrical Specialty Code Edition:
Springfield Fire Code Edition:
Path 1A Gas.fired furnace Mechanical Specialty Code Edition:
Municipal! Development Code:
Plumbing Specialty Code Edition:
Residential Specialty Code Edition:
Structural Specialty Code Edition:
10/1/2010 6:54:30AM
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage:
Sq Ft Carport:
Sq Ft Other:
Occupancy Load:
5780
1519
420
2008
Page 1 of6
W.WW. ci. springfield. or. us
PROJECT STATUS: Issued
CITY OF SPRINGFIELD
Building I Residential Permit
PERMIT NO: COM2010-01026
IVR Number: 811000054208
225 Fifth St
Springfield,OR 97477
Phone: 541-726-3753
Inspection Phone: 541-726-3769
Fax: 541-726-3676
permitcenter@ci.springfield.or.us
ISSUED: 9/16/10
APPLIED: 7/30/10
EXPIRES: 3/26/2011
VALUE: $163,024.00
. SITE ADDRESS: 4120 STELLAR WAV Springfield
ASSESOR'S PARCEL NO: 1802061419200
SCOPE: SFD
WORK INVOLVED: NEW
TYPE OF STRUCTURE: RES
PROJECT DESCRIPTION:
Engineered Fill:
Fill Volume:
Flood Hazard Area:
Land Hazard Area:
Retaining Wall:
Soils Report Required:
No
No
No
No
No
Single family residence - Same as COM2010-00256 10335 41st - Related (child) record
811-SPR2010-00053
I Site Information ~
Frontyard Setback:
Interior Setback:
Sideyard Setback:
Rearyard Setback:
Solar Setback:
18.00
5.00
12.00
21.00
DEVELOPMENT INFORMATION ~
Overlay Dist:
# Street Trees Reqd:
Paved Drive Reqd:
% of Lot Coverage:
Highest point on structure to
north property line:
REQUIRED PARKING
2
Ves
34.60
Total: 2
Handicapped:
Compact:
11.50
Street Improvements:
Storm Sewer:
Storm Sewer Available:
Speciallnstructon:
Subdivision Accepted:
Notes:
Storm drains to curb and gutter
FI
CG
Ves
Descriotion
Bid
Springfield Building Permit
PUBLIC IMPROVEMENTS ~
Sidewalk Type: C5
DownspoutJDrains:
Valuation Description ~
Tvoe of Construction
NA
Unit Amount Unit Tvoe
163,024.00 Bid
Unit Cost
1.00
Value
163,024.00
163,024.00
10/1/2010 6:54:30AM
Page 2 of6
CITY OF SPRINGFIELD
Building I Residential Permit
PERMIT NO: COM2010-01026
IVR Number: 811000054208
S~~~NG..,._.FIE. ,~.D.
~.~
" ~
. 1" OREGON
www.ci.springfield.or.us
225 Fifth St
Springfield,OR 97477
Phone: 541-726-3753
Inspection Phone: 541-726-3769
Fax: 541-726-3676
permitcenter@ci.springfreJd.or.us
PROJECT STATUS: Issued
ISSUED: 9/16/10
APPLIED: 7/30/10
EXPIRES: 3/26/2011
VALUE: $163,024.00
SITE ADDRESS: 4120 STELLAR WAY Springfield
ASSESOR'S PARCEL NO: 1802061419200
SCOPE: SFD
WORK INVOLVED: NEW
TYPE OF STRUCTURE: RES
PROJECT DESCRIPTION:
O:\",!i'i(;';~!\;ii'T:;\j>W,"
Single family residence - Same as COM2010-00256 1033 S 41st - Related (child) record
811-SPR2010-00053
;,ryi" "",':!'; ,:"t"irmLWJn\\;V" ',.'f" ,/~hM1m1l1!h,1 lUll;.!;':>;,".
:~'rh0A;:l ,:JjU < i"". ,'" ' \,:"li"!j
,!FEESP.AID',')
Amount Paid
$250.00
$101.65
$279.54
$141.69
$211.00
$101.97
$10.00
$-914.66
$740.60
S-254.35
$1,238.32
$254.35
$1,333.57
$914.66
$-45.00
$88.00
$88.00
$22.63
$1,140.17
$63.00
$374.00
$13.00
$3,468.00
$38.00
$7.00
$84.86 .
$884.37
$96.95
$50.00
$134.00
$79.00
$17.00
$36.00
$9.00
$9.70
$89.46
$210.15
$11,365.63
Descriotion
Plan Review Same As
SDC Transportation Admin
SDC Transpo Reimbursement
SDC SanitarylStorm Admin
Plan Review Major - Planning
SDC MWMC Reimbursement
SDC MWMC Administration
Credit- SDC Storm Improv
Sanitary Sewer - Improvement
Credit- SDC Storm Reimb
Sanitary Sewer - Reimbursement
SDC Storm - Reimbursement
SDC MWMC Improvement
SDC Storm - Improvement
Curbcut - 2nd Curbcut
Curbcut Permit
Sidewalk Permit
SDC MWMC Compliance Charge
SDC Transpo Improvement
Temp services 200 amps or less
One or Two Family Dwellin9 with Two Bath
Range hoodlother kitchen equipment.
Willamalane fees - Sin91e family detached
Address Assignment, each new or change
Gas Pipin9 up to 4 outlets
Structural Buildin9 Permit Fee
Structural Building Permit Fee
Residential Fire (.05 Per Sq Foot)
Each added 500 sq. ft. or portion
Residence wiring 1,000 sq. ft. or less
First Appliance Fee
Heat pump
Sin9le-duct exhaust (bathrooms, toilet compartments, utili
Flue vent for water heater or gas fireplace
Admin fee (10% of applicable fees)
Technology fee (5% of permit total)
State of Ore90n Surcharge (12% of applicable fees)
Total Amount Paid
Springfield Building Permit
10/1/2010 6:54:30AM
Date Paid
07/30/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
09/16/2010
Receiot #
23258
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
. 374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
374322
Page 3 of6
www.ci.springfield.or.us
CITY OF SPRINGFIELD
Building I Residential Permit
PERMIT NO: COM2010-01026
IVR Number: 811000054208
225 Fifth St
Springfield,OR 97477
Phone: 541-726-3753
Inspection Phone: 541-726-3769
Fax: 541-726.3676
s.rRINGFIE~
~
OREGON
permitcenter@ci.springfield.or.us
PROJECT STATUS: Issued
ISSUED: 9/16/10
APPLIED: 7/30/10
EXPIRES: 3/26/2011
VALUE: $163,024.00
SITE ADDRESS: 4120 STELLAR WAY Springfield
ASSESOR'S PARCEL NO: 1802061419200
SCOPE: SFD
WORK INVOLVED: NEW
TYPE OF STRUCTURE: RES
PROJECT DESCRIPTION:
Single family residence. Same as COM2010-00256 1033 S 41st - Related (child) record
811.SPR2010-00053
L .;',:,,\'1 "m':~..
p 'l1"'.,
"<>;\;\'" '.il#,ihhi; '\iWil.1!I!U1m~ml;~'i:';': :;L};;'T',};rrNniffi~;f,:j ,,:;i;.\jijjl";iji " l'
Elan"Review
DeDartment Received Due Date ComDlete Result Reviewer
Planning Review 08/05/2010 APP
Public Works Review 08/06/2010 APP
Public Works Review 09/16/2010 Q8109/2010 08/09/2010 Approved Ben Gibson
Structural Review 08/17/2010 08/09/2010 08/09/2010 Approved Chris Carpenter
Application Acceptance 07/30/2010 08/09/2010 Application Accepted Chris Carpenter
Initial Review 08/01/2010 08/09/2010 08/09/2010 Approved Chris Carpenter
Inspection 09/17/2010 09/16/2010 09/16/2010 In Process Guy Dixon
Permit Issuance 09/16/2010 08/17/2010 08/1712010 Issued Usa Hopper
Planning Review 09/16/2010 08/09/2010 08/09/2010 Approved Deyette Kelly
Comments
Required street trees as sho~
Storm water to curb and guttE
As noted on plans I review Ie'
See workflow history
Inspectio.n in process
Springfield Building Permit
10/1/2010 6:54:30AM
Page 4 of 6
CITY OF SPRINGFIELD
225 Fifth St
Springfield,OR 97477
Phone: 541-726-3753
Inspection Phone: 541-726-3769
Fax: 541-726-3676
WNW.ci.springfield.or.us
Building I Residential Permit
PERMIT NO: COM2010-01026
IVR Number: 811000054208
permitcenter@ci.springfield.or.us
PROJECT STATUS: Issued
ISSUED: 9/16/10
APPLIED: 7/30/10
EXPIRES: 3/26/2011
VALUE: $163,024.00
SITE ADDRESS: 4120 STELLAR WAY Springfield
ASSESOR'S PARCEL NO: 1802061419200
SCOPE: SFD
WORK INVOLVED: NEW
TYPE OF STRUCTURE: RES
PROJECT DESCRIPTION:
Single family residence - Same as COM2010-00256 1033 S 41st. Related (child) record
811-SPR2010-00053
INSPECTIONS REQUIRED ,
Inspections
1090 Street Trees
1110 Footing
1120 Foundation
1150 Slab/Flatwork
1160 UFER Ground
1170 Post & Beam
1260 Framing
1410 Underfloor insulation
1420 Insulation ~apor Barrier
1430 Insulation Wall
1440 Insulation Ceiling
1520 Interior Shearwall
1530 Exterior Shearwall
1540 Gypsum Board/lath/Drywall
1999 Final Building
2200 Underfloor Mechanical
2210 Underfloor Gas
2260 Gas Service
2300 Rough Mechanical
2310 Rough Gas
2995 Final Gas
2999 Finai Mechanical
3130 Footing/Foundation Drains
3170 Underfloor Plumbing
3200 Sanitary Sewer
3315 Water Line
Springfield Building Permit
10/1/2010 6:54:30AM
Page 5 of6
www.cLspringfield.or.us
CITY OF SPRINGFIELD
Building I Residential Permit
PERMIT NO: COM2010-01026
IVR Number: 811000054208
225 Fifth St
Springfield,OR 97477
Phone: 541-726-3753
Inspection Phone: 541-726-3769
Fax: 541-726-3676
S~R.INGFIEL~
~1t.~4-
',~
I", OREGON
permitcenter@ci.springfieJd.or.us
PROJECT STATUS: Issued
ISSUED: 9/16/10
APPLIED: 7/30/10
EXPIRES: 3/26/2011
VALUE: $163,024.00
SITE ADDRESS: 4120 STELLAR WAY Springfield
ASSESOR'S PARCEL NO: 1802061419200
SCOPE: SFD
WORK INVOLVED: NEW
TYPE OF STRUCTURE: RES
PROJECT DESCRIPTION:
Single family residence. Same as COM2010.002561033 S 41st. Related (child) record
811-SPR2010-00053
3400 Storm Sewer
3500 Rough Plumbing
3999 Final Plumbing
4225 Service or Feeder
4500 Rough Electrical
4999 Final Electrical
4000 Temporary Power Service
1120 Foundation
3170 Underfloor Plumbing
3315 Water Line
3200 Sanitary Sewer
3400 Storm Sewer
3411 Perimeter Rain Drains
3170 Underfloor Plumbing
1170 Post & Beam
2200 Underfloor Mechanical
2210 Underfloor Gas
3170 Underfloor Plumbing
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 or 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 Contractor Signature
Date
Springfield Building Permit
10/1/2010 6:54:30AM
Page 6 of 6
Electrical Permit Application
CITY OF SPRINGFIELD, OREGON
I
225 Fifth Street. Springfield, OR 97477. PH(541 )726-3753. FAX(541 )726-3689
.,(.'." ','. - '''-'-" .'.
, DEP,ARTNiENT USE ONLY;;
Permit no:C1P - Olc)Zb
Date:
This permit is issued under OAR 918-309-0000. Permits are nontransferable. Permits expire if work is not started within 180
days of issuance or if work is suspended for 180 days.
" ',[OCAV GOVERNMENT:AP.PROIJAli'y:';.::,i'/i
Zoning approval verified? 0 Ves 0 No
c'ii,CATEGORY;(jfCONSTRUCTIOfoj':?, <i.i'" '
Residential D Government D Commercial
, ~-It.'&i!>>!;;:Jos:;,srtE:: JNfQRNiA:rJOI'4N\Njj!,;L(jCAT:JOI'4~Y\~;:;ir
Job site address: J Z 0 5 ~ II c... V
City:
\
Reference: '.
PROPERTY, OWNER
Name: e,'(\IU W; ec-he.A CJ;.-!-e",
Address: 307 :s s)c. ) J..J
City:(u u-<-- ZIP: er7tO)
Phone:SW -bzb Of .> ~ Fax: GVI-'3Yf :;3b 'Z-
E-mail: W;t.c-I.e~t-\-.()~.s 18 C<:>~C.A'>+, lVc..r
This installation is being made on residential or farm property
owned by me or a member of my immediate family. This
property is not intended for sale, exchange, lease, or rent. OAR
479.540(1) and 479,560(1).
Signature:
: CONTRACTOR INSTALLATION
Business name: I- 4- e f -ec,+"'; C-
Address: Z 3 33 -Sov-es. Ac.('e-S
City: S f \~ State: 0 l'L ZIP: q 7 'f '7 ~
Phone:~'f1-5ZI- 4' 'i l Fax: '51-f1 -q33-- z.::,"1'6
E-mail:
CCB license no.: I OS- 4 7S- BCD license no.: 3 'i3; <::--
Signing supervisor's license no.: '11 7 '1- S--
Print name of signing supervisor: ~ () V. "cvV.G.>-
Signature of signing supervisor:
~\J~~ ~tJ' q'
~}-q ~4';
t> 'iJ&'><O
440-2584-) (9/08/COM)
'\~';"::'~~:~H~.~@S$t;:~~,\:;\~~'?';:F,:EE~1,:SCH E.O_liJjE;;2\~!;~::;Wi~\1:~W~~~~l':;~};~0>W:,i,~:%1
Numberofillipections per i;itn()., Qty. . Cost Total
'., :"," ,"',- :" ; .....':-;',.. ,-.."",; .,:..',_: ea.:: . co_sf. '('.
Residential, per unit, service included:
1,000 sq, ft. or less (4) I $134,00 $ r1'1
Each additional 500 sq. ft. or portion U $ 25.00 $ 5'0
thereof
Limited energy (2) $ 32,00 $
Each manufactured home or modular $ 63.00 $
dwelling service or feeder (2)
Services or feeders: installation, alteration, relocation
200 amps or less (2) ~ $ 81.00 $
20 I to 400 amps (2) $ 95,00 $
401 to 600 amps (2) $158.00 $
601 to 1,000 amps (2) $205.00 $
Over 1,000 amps or volts (2) $469.00 $
Reconnect only (2) $ 63.00 $
Temporary services or feeders: installation, alteration, relocation
200 amps or less (2) 7 $ 63.00 $.. ~
20 I to 400 amps (2) $ 87,00 $
401 to 600 amps (2) $126.00 $
Over 600 amps or 1,000 volts, see services or feeders section above
Branch drcuits: new, alteration, extension per panel
a. Fee for branch circuits with purchase of a service or feeder fee:
Each branch circuit $ 6.00 $
b. Fee for branch circuits without purchase of a service or feeder fee;
First branch circuit (2) $ 55,00 $
Each additional branch circuit $ 6.00 $
Miscellaneous fees: service or feeder !lot included
Each pump or irrigation circle (2) $ 63.00 $
Each sign or outline lighting (2) $ 63.00 $
Signal circuit or a limited-energy panel, $ 63.00 $
alteration, or extension (2)
Each additional inspection: (1) $58.00 $
..~~~~gplti~}t~:lb~~i~f~ j.tH~~?1~;\'A~J~ Lic"ANt/J,J s Er~~,;,;~~;;,:/~~~:~.,~~~::";:'D;>;::. :i; .:;'~~', ':' :.
(A) Enter subtotal of above fees $z..\.{7
(Minimum Permit Fee $58.00)
(B) Enter 12% surcharge (.12 x [A]) $ Z '7bl
(C) Technology Fee (5% of [A]) $ IZ::J
TOTAL rees and surcharges (A through C): $70-'"
~
5'~
~~'/'I\V~.s I Cl ~ 3 $ '-J ,st-
Structural Permit ApplicatioD_ Cro. Z $ '=-
CITY OF SPRINGFIELD, OREGON
,
.....~.......
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DEf'ARfMEN'fi.ls~6N~- ,
.' . ."i.',. ,'.' "".'...'\'i'".~.'~~'. c.. ". -. )~:;P'"
C()rHZ~'O .O/OZ b
Pennit no.:
+5 P 1&\0-
225 Fifth Street. Springfield, OR 97477. PH(541)726-3753. FAX(S41)726_3689
Date: '0 '0
This permit is issned under OAR 918-460-0030. Permits expire if work is not started within 180 days orissuance or fwork is
suspended for 180 days.
Date:
Date:
DYes
oNo
C",b.... I>.,,,..a.~ :I:1vL
L",
State:O<L ZIP: '17Y<> I
Fax: ~(t - 336 z
@ GO'''' U-5-1 ~ v-Jc-t
Name
Eleelrical /.... ~
Plumbing 5lC"" I
Mecbanic:a' ( t')-t
Sll 'II i (,
, Yl-3"l 10,
7 lb"oloe)
i;v'{iii~ti6"lli
.,' .... ."......'1",...-
(a) lob description:
Occupancy
Construction type:
Square Ceet:
Cost per square Coot:
Other infonnation:
Type orReat: F (;~
Energy Palb:
,la11eW 0 alteration
(b) Foundation-only pennit?
o addition
DYes
.f:3-No
Total valuation:
.. 2. Bullc'liM(f~e~;'?;~'~.l.!"<
(a) Pennit Cee (use valuation table):
(b) Investigative Cee (equal to [2a]):
(c) Reinspection (S per hour):.
(number oChours x fee per hour)
$
$
$
(d) Enter 12% surcharge (.12 x [2a+2b+2c]): $
(e) Subtotal orrees above (2a tbrougb 2d): $
'ijpljlij)~ H' :.. .,:i
(a) Plan review (65% x pennit Cee [2a]):
(b) Fire and life safety (40% x permit fee [2a]):
(c) Subtotal orrees above (3a and 3b):
. 4. M.1~ce.i!ii'lie~ii'Sie~'(.,
(a) Seismic Cee, 1% (.Ol x pennil Cee [2a]): $
TOTAL rees and ..rcharge. {2e+3c+4aJ: $
. 2~wiUamalane
tlJ . Park and Recreation District
Job. No. tilt) -/0;2..(:..
SYSTEM DEVELOPMENT CHARGE WORKSHEET
July 1-December 31,2010
NAME:>>I.A.!E cJle:C.H€'KT ~TOWl f-hmqHONE: ~0- 9'1$'6
ADDRESS:!6';2? ~y V/EftJ CITYG"tA<(. STATE:M. ZIP:'1'}7tJ.r
LOCATION OF PROPOSED BUILDING SITE:
Street Address: '1/;2 0 ~ IV i'
Plat Name:J0tst \0\ (Vi ~ . Tax Lot Number: '<&07..0b \", \ q 7.Jj) .
1.. DEVELOPMENT TYPE (CheckapPrOpiiate dwelling(s). Dwelling type definitions are on the
back.) .
A. SinGle-Family Detached
NO. OF UNITS. {
X $3,468 per unit =
$ 0'1fo'6
B. SinGle-Family Attached
NO. OF UNITS
X $3,5.38 pe.r unit =
$
C. Multi-Family Apartmerit.
NO. OF UNITS
X $2,906 per unit =
$
. D. SinGle Room Occupancy.
NO. OF UNITS.
X $1,453 per unit =
$
E. Accessory DwellinG Unit
NO. OF UNITS
X $1 ,734 per unit =
$
$
WILLAMALANE SDC
2. SDCCREDIT (If applicable) SDC payer must furnish proof of
Willamalane Credit approval.)
$
0'
.3: TOTAL WILLAMALANE NET SDC ASSESSED
(if SDC reduced for Credit)
.~
Development Services. Department
City of Springfield
$ .J'fEJ
tY ,L!0 /6
Date
5
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
City of Springfield Official Receipt
Development Services Department
Public Works Department
RECEIPT #:
1201000000000000849
Date: 07/30/2010
I :34:04PM
Job/Journal Number
COM2010-01026
Payments:
Type of Payment
CreditCard
cRcccintl
Description
Plan Review Same As
Paid By
BWCH
'" ~
,1"Jr:"
"y~':' . ... ,
1";. ~
j;_-"J
Received By
, 'Check Number
Batch Number
djb
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:~J' .:', ".'1
,'-1,-.4"
. . \ ~ ,
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... . '.
',"'
"'f .~.
, .
!:'.t;' ,r,. , /..,....
.' '. oj"" "~'I'
,:.,'._..i'r~ ..... ",-",.;,
>"j' '
Page I of I
Item Total:
Authorization
Number
Amount Due
250.00
$250.00
How Received
Amount Paid
03524d In Person
Payment Total:
$250.00
$250.00
7/30/2010
~