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Home My WebLink AboutOccupancy Building 2004-1-6 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line . . CITY OF SPRINGFIELD. Building/Combination Permit PERMIT NO: COM2003-01237 ISSUED: 01106/2004 APPLIED: 12/11/2003 EXPIRES: 07/06/2004 VALUE: $ 132,782.00 SITE ADDRESS: 4038 Douglas Dr ASSESSOR'S PARCEL NO.: 1802061111500 PROJECT DESCRIPTION: SFR Springfield TYPE OF WORK: Single Family Residence TYPE OF USE: New Residential Owner: BRUCE WIECHERT Address: 3375 PARK HILLS EUGENE OR 97405 Contraclor Type General Electrical Mechanical Pluml)jng Phone Number: 541-686-9458 I CONTRACTOR INFORMATION I Contractor BRUCE WIECHERT CUSTOM HOMES INC L & E ELECTRIC INC COMFORT FLOW STEVE R JOHNSON Phone 541-686-9458 541-933-2653 541-726-0100 541-342-3765 # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Cunstruction Type: # of Bcd rooms: SETBACKS Frolllyanl St.thack: Side I Selh",": Side 2 Sl'lh4lck: 18.00 5.00 10.00 19.00 30.00 Rt.'aryanl Set hack: Sular Setbae"s: Street Improvements: Storm Srwl'r Available: Spl'cial Inst rllcHon: License 101717 105475 460 65065 Expiration Date 09/16/2006 03/30/2004 06/27/2005 03/1212004 I. BUILDING INFORMATION' I R-3 U-I VN # of Stories: I Lot Size: Height of Structure 24.00 Sq Ft Ist Floor: Type of Heat: Forced Air Gas Sq Ft 2nd Floor: Water Type: Gas Sq Ft Basement: Range Type: Electric Sq Ft Garage/Carport Ener~~f\~N'Ore9on la"atlqlllre!Sl{lW. f;5ther: All ri pted by the Or9gCliltp\!~\lIus Surface Area: I~' rIJI'3C', A n t _ _.._ ~at 'nrt I DEVE~~N;~~mA.til5iS..:ih~OAR 952-00 n U~n J...t.J.. .. . copies of the rules REQUIRED PARKING " an You may obtatn ~\"etIi\~.!!\\\~ center. (Note: the tel~phO~~otal: 2 # S'tl\\~l ~fes fuW'Oregon Utility NiZ'tlflcatIOUandicapped: PllWlil~rlveOJ{~'d:. 1 nnn_332-2"l44). Compact: ,............~,..,.. l~"''''''' Yes % of Lot Coverage: 30.50 5,850 1,350 440 3 I PUBLIC IMPROVEMENTS I Sidewalk Type: Fullv Improved Curbside 5' Yes NOTICE: Down~p~ut~,J;ainsT THE \Gl!J\bi'8nd Gutter NO SEWER HOOK-UP OR OCCUPANqY\l1N1iiiWrrB'tlfc'IM~dYEMENT P-LA:I:i~ ARE ACCEPTED BY PUBLIC WORKS. AUTHORIZED UNDl:H I HI:> n:rllvl', IV .. . COMMENCED OR IS ABANDONED FOR ANY 180 DAY PERIOD. NOh.'s: Paee I of4 . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2003-01237 ISSUED: 01106/2004 APPLIED: 12111/2003 EXPIRES: 07/06/2004 VALUE: $ 132,782.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753I'hone 541-726-3676 Fax 541-726-3769 Inspection Line I Valuation Oescriotion I Dcsrriution Tvpe of Construction $ Per Sq Ft Square Footage or multiplier or Bid Amount Dwl'llinus V Wood Frame $90.60 1,350.00 Caracc Garat!e $23.80 440.00 Value Date Calculated Total Value of Project $122,310.00 $10,472.00 $132,782.00 12/1112003 12/1112003 ~ Fpp<. p"W Fce Ilcscriution Amount Paid Date Paid Receipt Number Plan l{c\'h~\\' Residential $437.39 12111103 1200200000000002583 .....i\h'l.hanil'al Issuance Fee- $10.00 1/6/04 1200400000000000010 + IOIX. Administrative Fee $114.09 1/6/04 1200400000000000010 + 71}';, Stale Surcharge $79.86 1/6/04 1200400000000000010 2 Baths Onc or Two Family $254.00 1/6/04 1200400000000000010 Addn'ssing Assignment $8.00 1/6/04 1200400000000000010 Appliance Vent $6.00 1/6/04 1200400000000000010 Building Permit $672.90 1/6/04 1200400000000000010 Curhent - Ovcrwidth Appl $35.00 1/6/04 1200400000000000010 Curh".'ut Permit $75.00 1/6/04 1200400000000000010 Ilry"'r VC.'lIt $6.00 1/6/04 1200400000000000010 Exhaust Iloods $9.00 1/6/04 1200400000000000010 Furn,"'e - "11 to 100,000 btu $12.00 1/6/04 1200400000000000010 C~IS Fin'placc $15.00 1/6/04 1200400000000000010 Gas Olltlels 1-4 $4.00 1/6/04 1200400000000000010 Plan l{c"it'w. Planning $59.00 1/6/04 1200400000000000010 I'W ,\J1I1t Disc - 2nd Permit $-30.00 1/6/04 1200400000000000010 Resid"lIce Wiring 1000 Sq Ft $106.00 1/6/04 1200400000000000010 Resi<"'"",' Wiring Ea AddU 500 $38.00 1/6/04 1200400000000000010 Sallil:lr~' Sewer - Improvement $361.41 1/6/04 1200400000000000010 Sal1il:lr~' Sewer - Reimbursement $475.44 1/6/04 1200400000000000010 SDC MW,\IC Administration $10.00 1/6/04 1200400000000000010 SDC ~l\nlC Improvement $214.23 1/6/04 1200400000000000010 SDC ~1\nIC Reimbursement $314.63 1/6/04 1200400000000000010 SDC Sallitary/Storm Admin $105.85 1/6/04 1200400000000000010 snc Trallspo Admin $53.68 1/6/04 1200400000000000010 SDC Trallspo Improvement $727.42 1/6/04 1200400000000000010 SDC Tr:lllspn Reimbursement $164.89 1/6/04 1200400000000000010 Sidewalk !'l'rmil $75.00 1/6/04 1200400000000000010 Slnrm Drainage Impervious Area $922.64 1/6/04 1200400000000000010 Vl'lIt F:1I1 $18.00 1/6/04 1200400000000000010 ".'ill:lIllalilllc Single Family $1,000.00 1/6/04 1200400000000000010 Tola' Amount Paid $6,354.43 Pat!e 2 of 4. . . CITY OF ~rKll~GFIELD Building/Combination Permit PERMIT NO: COM2003-01237 ISSUED: 01106/2004 APPLIED: 12111/2003 EXPIRES: 07/06/2004 VALUE: $ 132,782.00 Status Iss u ed 225 Fifth Strect, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-37(,9 Inspcction Line Initiallh'\'icw PliJllninu Review Puhlk '''orks Review 12/1212003 12/12/2003 12/12/2003 I Plan Reviews I 12/1212003 APP 12/31/2003 APP 12/26/2003 APP RJB TAJ VRJ NO SEWER HOOK-UP OR OCCUPANCY UNTIL PUBLIC IMPROVEMENT PLANS ARE ACCEPTED BY PUBLIC WORKS. Applicant has applied for Overwidth Driveway application, PW Transportation is reviewing application, 12/26/2003. Stnl('fllral Review 12/12/2003 12/29/2003 APP TCM To Hcqllcst all inspection call the 24 hour recording at 726-3769. All inspection requested before 7:00 a.m. willbc made the same working day, inspections requested after 7:00 a.m. will be made the following work day. I Rpnnirprl Tnsnections I 1 Sidewalk - Curbside: After forms are erected but prior to placement of concrete. 2 Curhcut - Standard: After forms are erected but prior to placement of concrete. 3 Ufcr Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing and/or foundation inspection. 4 Fuoting: After trenches are excavated. 5 Fuuudation: After forms are erected but prior to concrete placement. 6 Pust and Bcam: Prior to floor insulation or decking. 7 Flour Insulation: Prior to decking. 8 Shear Wall Nailing: Before covering sheathing with finish materials. 9 Framing Inspection: Prior to cover and after all rough in inspections have been approved. 10 Wall Insulation: Prior to cover. 11 C,'jling Insulation: Prior to cover. 12 Dl'nvall: Prior to taping. 13 Fiual Building: After all required inspections have been requested and approved and the building is complete. 14 lJ'ltlerfloor Plumbing: Prior to insulation or decking. 15 Undl'rfloor Drain: Prior to cover or placement of concrete. 1(, J{uugh Plumbing: Prior to cover and including required testing. 17 WalerLine: Prior to filling trench and including required testing. 1 R Sa n itary Scwer Line, Prior to filling trench and including required testing. 19 Slurm Sewcr Line: Prior to filling trencb. 20 Final Plumbing: When all plumbing work is complete. 21 Uuderfloor Mecbanical. Prior to insulation or decking and including required testing. 22 J{uugh Gas: After line is installed and required testing and capped jfnot attached to an appliance. 2J Cas Servkc: After line is installed and line has been connected to a minimum of one appliance including required tl'sl ing. Presure test done at this point. 24 Rough Ml'chanical: Prior to Cover 25 Fiual Gas: When all gas work is complete: 2(, Fiual Mcchanical: When all mechanical work is complete. 27 nUlIgh Electric: Prior to Cover Pace 3 of 4 . . Ll1 i' OF ~rK11~\.J1'lELD Building/Combination Permit PERMIT NO: COM2003-01237 ISSUED: 01/06/2004 APPLIED: 12/1112003 EXPIRES: 07/06/2004 VALUE: $ 132,782,00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541- 726-3769 Inspection Line 2S Eketric Service: Approval required prior to utility company energizing service. 29 Final Elcctrlc: When all electrical work is complete. By signaturc, I state and agree, that 1 have carefully examined the completed application and do hereby certify that all inforlllalion hercon 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 thai iW) OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I fUrlhl'r certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I fnr.hl'r agrcc to cnsure that all requi inspections are re -arthe proper time, that each address is readable from the 'tn'l'l. that the permit c . oc at tbe fro e property, and the approved set of plans will remain on the site at all tillles d?71truc I) b /0 'I OWlll'ri;';:' Co~ D'te / Pa2e 4 of 4 225 Fifth. Street Springfield, Oregon 97477 541-726-3759 Phone Jub/Juurlwl i\"lImher COM2003-01237 COM2003-01237 COM2003-01237 COM2003-0 123 7 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-0l237 COM2003-0l237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-0l237 COM2003-0l237 COM2003-0 123 7 COM2003-01237 COM2003-01237 COM2003-0 123 7 COM2003-0l237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-01237 COM2003-0 123 7 Payments: Type of Payment CreditCard &P~ ~~ Rcccipt #: 12UU40000UOOOO(l(IO I U DC~l:riplion Addressing Assignment Willamalane Single Family Sidewalk Permit Curbcut Permit Curbcut - Overwidth Appl PW Mull Disc - 2nd Pennit Stonn 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/Stonn Admin SDC Transpo Admin Building Permit 2 Baths One or Two Family Furnace - up to 100.000 btu Exhaust Hoods Applianc~ Vent Dryer Vent Gas Outlets 1-4 Gas Fireplace Vent Fan -Mechanical Issuance Fee- Plan Review - Planning Residence Wiring 1000 Sq Ft Residence Wiring Ea Addtl 500 + 7% State Surcharge + 10% Administrative Fee Received By djb Check Number Batch Number Authorization Number Paid By BRUCE WIECHERT CUSTOM 000268 051706 City of Springfield Official- Receipt Dcvelopmcnt Services Department" Public Works Departmenf Date: 011tJ6/2U04 I O:29:3HAM < Amount Paid Item Total: 8.00 1.000.00 75.00 75.00 35.00 (30,00) 922.64 475.44 361.41 164.89 727.42 314.63 214.23 10.00 105.85 53.68 672.90 254.00 12,00 9.00 6.00 6.00 4.00 15.00 18.00 10.00 59.00 106,00 38.00 79.86 114.09 $5,917.04 . . How Received In Person Payment Total: Amount Paid $5,917.04 $5,917.04 , . CITY OF SPRINGFIELD SYSTEMS DEVELOPMEN-IORKSHEET JOURNAL OR JOB NUMBER: Com2003-01237 NAME OR COMPANY: Custom Homes LOCATION: 4038 Douglas Drive TAX LOT NUMBER: 180206111111500 DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE NEW DWELLING UNITS I BUILDING SIZE (SF' 1308 LOT SIZE (SF): I. STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM 1 IMPERVIOUS S,F, x 1 COST PER S.F. I I CHARGE I 3181.50 I $0,290 = I $922.64 I RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS 1 IMPERVIOUS S.F. 1 x 1 COST PER S.F. I x I DISCOUNT RATE 1 I DISCOUNT I 0.00 1 $0,290 I 50% 1 = $0.00 ITEM I TOTAL - STORM DRAINAGE SDC 5922.64 I 2. SANITARY SEWER - CITY A. REIMBURSEMENT COST: I NUMBER OF DFU's I x 1 COST PER DFU 1 21 1 $22.64 B. IMPROVEMENT COST: 1 NUMBER OF DFU's I x COST PER DFU 1 21 $17,21 ITEM 2 TOTAL - CITY SANITARY SEWER SDC =, 5850 5922.64 5475.44 5361.41 5836.85 3. TRANSPORTATION A. REIMBURSEMENT COST: I ADT TRIP RATE I x 1 NUMBER OF UNITS I I 9,57 I 1 I B. IMPROVEMENT COST: I ADT TRIP RATE I x 1 NUMBER OF UNITS I I 9j7 1 I I ITEM 3 TOTAL - TRANSPORT A TJON SDC x 1 COST PER TRIP x INEW TRIP FACTOR I I $17,23 1.00 x 1 COST PER TRIP x INEWTRlPFACTORI 1 $76.01 1.00 = , 5892.31 5164.89 5727.42 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: INUMBER OF FEU's 1 x ICOST PER FEU 1 I 1 $314.63 B. IMPROVEMENT COST: INUMBER OF FEU's 1 x I COST PER FEU 1 .1 I $214.23 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL - MWMC SANITARY SEWER SD< = , SUBTOTAL (ADD ITEMS 1,2,3, & 4) ~ , 5. ADMINISTRATIVE FEE: ISUBTOTAL I x ADM. FEE RATE 1= 1 $3,190.66 1 5% 1 TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: = 5314.63 = 5214.23 50.00 510.00 5538.86 53,190.66 CHARGE $159,53 105.85 Iii o u ~ ~ 'f-< ~ '" G ~ 'I 1070 I 11091 I 11092 II 11093 1094 1054 1055 1054 1056 1079 12/26/2003 TOTAL SDC CHARGES $53.68 1078 ----=.!_ S3,3S0.1C]1 Virginia Jurasevich PREPARED BY DATE . . . . DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIV AlENT ~ DRAINAGE FIXTURE UNITS (NOTE: FOR REMODELS, CALCULATE ONL V THE NET ADDmONAL FIXTURES) NO. OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUIVALENT UNITS IBATHTUB -2 0 ~ = 6 IDRINKING FOUNTAIN 0 0 1 = 0 IFLOOR DRAIN 0 0 3 = 0 IINTERCEPTORS FOR GREASE 1 OIL 1 SOLIDS 1 ETC 0 0 3 = 0 IINTERCEPTORS FOR SAND 1 AUTO WASH 1 ETC 0 0 6 = 0 ILAUNDRY TUB 0 0 2 = 0 ICLOTHESWASHER 1 MOP SINK 1 0 3 = 3 ICLOTHESWASHER - 3 OR MORE (EAt 0 0 6 = 0 IMOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 IRECEPTOR FOR REFRIG 1 WATER ST AnON 1 ETC 0 0 1 = 0 IRECEPTOR FOR COM. SINK 1 DISHWASHER 1 ETC. 0 0 3 = 0 ISHOWER. SINGLE STALL 0 0 2 = 0 ISHOWER, GANG (l'!UMBER OF HEADSl.. 0 0 2 = 0 ISINK: COMMERCIAURESIDENTIAL KITCHEN 1 0 3 = 3 ISINK: COMMERCIAL BAR 0 0 2 = 0 ISINK: WASH BASINIDOUBLE LAVATORY 1 0 2 = 2 ISINK: SINGLE LA V ATORY/RESIDENTIAL BAR 1 0 1 = 1 IURINAL. STALL! WALL 0 0 5 = 0 ITOILET. PUBLIC INSTALLATION 0 0 6 = 0 I ITOILET, PRIVATE INST ALLA TION 2 0 3 = 6 I MISCELLANEOUS DFU TYPE NUMBER OF EDU'S ,I 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 21 .EDU (Equivalent DwellinR Unit) is a disch~ equivalent to a sinJde family dwelling unit (20 DRYs) set at 167 gallons per day MWMC CREDIT CALCULA TION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 .1998 1999 2000 2001 CREDIT RATEI$ I ,000--' ASSESSED VALUE $5.04 SS.04 S4.95 $4.88 54.75 S4.58 $4.41 $4.20 $3.88 $3.50 $3.07 $2.60 $2.14 SL71 S1.52 S1.38 $1.19 $1.03 SO.87 SO.68 SO.46 $0.27 $0.09 $0.04 IS LAND ELGIBLE FOR ANNEXATION CREDIT? (Enler I for Yes. 2 for No) IS IMPROVEMENT ELGIBLE FOR ANNEX, CREDIT? (Enler I for Yes, 2 for No) BASE YEAR o o 1979 CREDIT FOR LAND (IF APPLICABLE) VALUE 11000 CREDIT RATE $0.00 x $5.04 ~ , $0.00 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALUE 11000 CREDIT RATE $0.00 x $5,04 o TOTAL MWMC CREDIT $0.00 = J . 'CITY OF 81 ~NGFIELD, OREGON " " "'. v- <'S' ~o 'lJ.7 \'?i- oJ::.00 'f:- 6~\V ~"'O<" ~0 ....'l).? 0 225 FIFTH STREET. SPRINGFIELD, OR 97477. PH:(541)726-3753 . FAX: (541)726-36!l9>eG~0" r:;,'1 " ELECTRICAL PERMIT APPliCATION >,:-0"-'" 0 000 City Job Number c..~\~""!::.1 Date \~I\~03 \"e'~,~~. ,~~ \ ,p o~ ....o~ 1'0' ~ ~ 3. ~~~~..i..I1:liE~~CiinwilTi1E.;BE.i{~' .. .. Mo: ~ fill ~.l 1--'; ~~~---:; ~ 1;\.0 00 o ~\1,; ., .,i~'..-;..'-~~III ''6~~..1 .'. ~~,~-. 1,.llil,'.1 ':" ulfi. am !)j p'er i1wellm l. IiO~\711~li:NSTJi'Il'r!..flJ{@~"" mfl- _I.' ,.... i.lI~' 40 -sa \)O\)~\o-..s d.,.... LEGAL DESCRIPTI"'6N I gOl 0<:; II 115"00 >F? Service Included 100.0. sq. ft. or less Each additional 50.0. sq. It or portion thereof $106.0.0. ,ob 3~ JOB DESCRIPTION 2. $ 19.0.0. Permits are non-transferable and expire jfwork is Each Manufact'd Home or not started within 180 days of issuance or jf work is Modular Dwelling Service or Suspended for 180 days. Feeder 2. 1II~~GCORhNS:tJtl.lJ<!A:iW.M'(.jlVtW'A B. li"S~~~'\Fi\eile~B~i+~ilti~v.::;'ti~~~e_ . ~!Jl;.....L' ''':.\~~'~.I ~iiZd ~~~~f'~IAWt:;,~,~':,,' '"' Electrical Contractor Lt: eEl p (')nG 20.0. Amps or less $ 63.0.0. d 20. I Amps to 40.0. Amps \0 $ 75.0.0. Address f..'Ji5.~ JtJf2LS Au-t.3 e 4DIAmPsto6DD~O~\~\\'l $125.0.0 . 60.1 AmP~o"d,~~Fsfi!'\\O~ $163.0.0 Phone '133 -J5'1F3 Overjo.~ ~~~9 g'O?,.J$) , $375.0.0 ''''~f.18!ll:i~,e \I-~ ~,.". $ 50.0.0. ~,O~' 609\9 ~Yi.<;; ,a\'!?J.' \.....e' ,"'(\.. Li/7U_5 ....-c'C.~ \",~j!:~" lJ.J'?~~. ~,.,,)r.~~ . '1 ' - (. 1 r>.\' .~\v!.',.. ml!!l! f.V! ~\liiil"M \0,'0,,1 \',0(\ ~'\:~~;\~,,~~~~ ~~~. 'f'\,\,ce; ~'O't ~~~'lI;l~~ti~~loeation ,Of."'..o\) ~~~~dP~,,,,"''2: "'O~O.~\,~~ R}\~fil:-tb,f&) Amps c~~'Oe~ A'IDps to 60.0. Amps (\oJ: Over 600 Amps or 100.0. Volls see "B" above. Signature of Supervising Electrician D. B~a-n'.hrGi~J(. r'/ /\ (l JJ . New Alte;:tion or Extension Per Panel /";if L.1J /wf A One Circuit ,,,o,~ 43.0.0. '---'. Each Additional Circuit or with '\\\'t. ~":\(\.'\ n W. .\^_ Service or Feeder Permit x.'t ,..\C,_"'1i3.oo OwnenNamel.",>,vc.e. \e(;.o1l~vt Cv':.~ ~.~.." .,. ~ '~:._"'~~\'[t~", '.. Address31.)~- {>~...IL l+;\\~ E~~~.~~~~~}~"$~~~~m City EvC-,py\p. Phone b~h-9Y.(11 '\'lih'il~~l@:~~~:'O~. $50..0.0. ~ Sifl!V~~~~""'v $ 50.00. OWNER INSTALLATION Lil1iiid~~~eSidential $ 25.0.0 The installation is being made on r,vr-';/ 1 own which Limitt.\t nergy/Commercial $ 45.0.0. is not intended for sale, lease or rent. . $50..0.0. City $p~ld Supervisor License Number Expiration Dale 10 - 0 I ~ 0 If Constr. Contr. Number I () 5 4 15" 3--30-olf $ 50..00 $ 69,0.0. $100..0.0. Expiration Date ':::--;-rt:,-f ."~ ~.!, ~ ,J"""I ~Jf.:"~ .., ;t~.... c:1' . .~...,~Ji,"~"'.t"'h ..~'.Al'''''('.'~~,.1l\~' It.'~~''' ~'! ~'.Lik Owners Signature: Minimum Electric Permit Inspection Fee is 545.00 + Surcbarges 4. iIb;.';;;'&,p.:t\l!-'ffiFj!.~li,a~ I UiJ ~.,~~ -,7 7% State Surcharge . f 0 0 ~ 10% Administrative Fee I L{ 'i 0 16%1.{8 TOTAL Inspection Request: 726-3769 Shared Drive(T:)/Building FormslElectrica1 Permit Am>liClllion ('()3.doc