HomeMy WebLinkAboutPermit Building 2005-5-23
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
.
. CITY OF ~r.KlNGFIELD
Building/Combination Permit
PERMIT NO: COM2005-00507
ISSUED: OS/23/2005
APPLIED: 04/29/2005
EXPIRES: 11123/2005
VALUE: $ 235,954.00
SITE ADDRESS: 3481 Falcon Dr
ASSESSOR'S PARCEL NO.: 1702194304700
Springfield TYPE OF WORK: Single Family Residence
TYPE OF USE: New
PROJECT DESCRIPTION: Single Family Residence, Ambleside Meadows subd lot 104
Residential
Owner: RIVER VALLEY BUILDERS INC
Address: PO BOX 2041
CORVALLIS OR 97339
Contractor Type
General
Electrical
Mechanical
Plumbing
Phone Number: 541-726-0330
I CONTRACTOR INFORMATION I
Contractor
RIVER VALLEY BUILDERS INC
G & E ELECTRIC INC
MIDWAY MECHANICAL INC
MIDWAY PLUMBING INC
Phone
541-367-1618
541-967-7045
541-928-2423
541-928-7927
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
Frontyard Setback:
Side 1 Setback:
Side 2 Sethack:
Rearyard Setback:
Solar Setbacks:
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
~\
License
134566
54468
154166
4687
Expiration Date
04/15/2007
09/15/2007
01130/2007
07/25/2008
1
R-3
U
VN
I BUILDING INFORMATION I
/.\ I I t:1~ IIUN: uregon law requires you to
# ot1Stbrlerules adopted by the oregbAt~ltm
HfigIIlfiItBQrQ~ter. Thos~~411bs aNt 16 oor:
TjpOIJJOO2-o01~<ltMJalYOAR9~1.loor:
WIl"'....;;JOW may obtain cop~of I'll j mment:
Ranl!.'!lI.~YI!nhe center.a< &tr6'ie tel ~(, ~ii'agelCarport
Enent;Y~~9! the Oregon ~~ N ' 3hher:
Sprinkled 'l:WUW'is 1 -2344\: uplllft Load:
I DEVELOPM.." 1 m..ORMATION ,
610
5,822
1,072
1.227
3
11.00
14.90
5.10
28.60
0.00
REQUIRED PARKING
Total: 2
Handicapped:
Compact:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
2
Yes
28.80
I rUDL1C.Il\1~RPYEMENTS I
,......,........
Fully Improved THIS PERMIT SHALL Ex~i~'twll'krj!.jtt>e~ORK
Yes AUTHORIZED UNDER TH\>.J>~spW~lQrll1!!~
COMMENCED OR IS ABANDONED FOR
ANY 180 DAY PERIOD.
Curbside 5'
Curb and Gutter
Pal!e 1 of4
.
.
CITY OF SPRINGFIELD
.
Status
Issued
Building/Combination Permit
PERMIT NO: COM2005-00507
ISSUED: OS/23/2005
APPLIED: 04/29/2005
EXPIRES: 11/23/2005
VALUE: $ 235,954.00
225 Fifth Street. Springfield. OR
541-726-3753 Phone
541-726-3676 Fax
541-726-37691nspection Line
I Valuation DescriotionJ
III r I
Description Tvpe of Construction $ Per Sq Ft Square Footage Value Date Calculated
or multiplier or Bid Amount
Dwellines V Wood Frame $96.00 2.299.00 $220,704.00 04/29/2005
Garaee Garaee $25.00 610.00 $15,250.00 04/29/2005
Total Value of Project $235,954.00
l..Fppo PiWU
Fee Description Amount Paid Date Paid Receipt Number
Plan Review Residential $654.97 4/29/05 1200500000000000543
-Mechanical Issuance Fee- $10.00 5/23/05 1200500000000000655
+ 10% Administrative Fee $145.47 5/23/05 1200500000000000655
+ 70/0 State Surcharge $101.83 5/23/05 1200500000000000655
3 Baths One & Two Family $306.00 5/23/05 1200500000000000655
Addressing Assignment $31.00 5/23/05 1200500000000000655
Addressing Assignment $31.00 5/23/05 1200500000000000655
Building Permit $1,007.65 5/23/05 1200500000000000655
Curbcut - Additional Driveway $40.00 5/23/05 1200500000000000655
Curbcut Permit $80.00 5/23/05 1200500000000000655
Dryer Vent $6.00 5/23/05 1200500000000000655
Exhaust Hoods $9.00 5/23/05 1200500000000000655
Furnace - up to 100,000 btu $12.00 5/23/05 1200500000000000655
Gas Fireplace $15.00 5/23/05 1200500000000000655
Gas Outlets 1-4 $4.00 5/23/05 1200500000000000655
Miscellaneous Mechanical $27.00 5/23/05 1200500000000000655
Plan Review Major - Planning $103.00 5/23/05 1200500000000000655
PW Disc - 2nd Permit (Street) $-30.00 5/23/05 1200500000000000655
Sanitary Sewer - Improvement $530.12 5/23/05 1200500000000000655
Sanitary Sewer - Reimbursement $697.16 5/23/05 1200500000000000655
SDC MWMC Administration $10.00 5/23/05 1200500000000000655
SDC MWMC Improvement $865.31 5/23/05 1200500000000000655
SDC MWMC Reimbursement $82.03 5/23/05 1200500000000000655
SDC Sanitary/Storm Admin $135.28 5/23/05 1200500000000000655
SDC Transpo Admin $62.51 5/23/05 1200500000000000655
SDC Transpo Improvement $772.49 5/23/05 1200500000000000655
SDC Transpo Reimbursement $175.13 5/23/05 1200500000000000655
Sidewalk Permit $80.00 5/23/05 1200500000000000655
Storm Drainage Impervious Area $823.52 5/23/05 1200500000000000655
Temp Power 200 amps or less $50.00 5/23/05 1200500000000000655
Vent Fan $18.00 5/23/05 1200500000000000655
Willamalane Single Family $1,000.00 5/23/05 1200500000000000655
Total Amount Paid $7,855.47
Paee 2 of 4
l,
.
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CITY 01< ~rKlNGFIELD
Status
Issued
Building/Combination Permit
PERMIT NO: COM2005-00507
ISSUED: OS/23/2005
APPLIED: 04/29/2005
EXPIRES: 11/23/2005
VALUE: $ 235,954.00
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
I Plan Reviews I
Initial Review 05/03/2005 05/03/2005 APP SKG
Plannine Review 05/03/2005 05/10/2005 APP TAJ
Public Works Review 05/03/2005 05/1112005 APP MS Storm drainage to weep hole to curb.
-MS
Structural Review 05/03/2005 05/05/2005 10 LLH Plans forwarded to Jason Bush for
plan review
Structural Review 05/05/2005 05/09/2005 APP JB Plans approved as noted
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.
'RPn~
Ufer Electrical Ground: InstaU 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 backi1ll.
Underfloor Plumbing: Prior to insulation or decking.
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.
Underfloor Mechanical. Prior to insulation or decking and including required testing.
Underfloor Gas: After line is Installed and required testing and capped if not attached to an appliance.
Rough Gas: After line Is installed and required testing and capped if not attached to an appliance.
Paee 3 of 4
.
. CITY OF SPRINGFIELD
Building/Combination Permit.
PERMIT NO: COM2005-00507
ISSUED: OS/23/2005
APPLIED: 04/29/2005
EXPIRES: 11/23/2005
VALUE: $ 235,954.00
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
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.
Temporary Electric: Approval required prior to Utility Company energizing pole.
Rough Electric: Prior to Cover
Electric Service: Approval required prior to utility company energizing service.
Final Electric: When all electrical work is complete.
Curbcut - Standard: After forms are erected but prior to placement of concrete.
Sidewalk - Curbside: After forms are erected but prior to placement of concrete.
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 1 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 p mit card ted at the front of the property, and the approved set of plans will remain on the site at all
times duri struct~
'5--2 > -l;!~5
c>~
Owner or Contractors Signature
Date
Paee40f4
CITY OF alNGFIELD SYSTEMS DEVELOPMEa.ORKSHEET
JOURNAL OR JOB NUMBER: COM2005-00507
NAME OR COMPANY: River Vallev Builders. Ine
LOCATION: 3481 Falcon Drive
TAX LOT NUMBER: 17021943 Tax Lot 04700
DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE
NEW DWELLING UNITS I BUILDING SIZE (SF: 0 LOT SIZE (SF):
L STORM DRAINAGE
DIRECT RUNOFF TO CITY STORM SYSTEM
I IMPERVIOUS S.F, x I COST PER S.F. CHARGE
I, 2656.50 1 $0.310 1 = I $823.52 1
RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS
1 IMPERVIOUS S,F. I x 1 COST PER S.F. 1 x I DISCOUNT RATE I I DISCOUNT
I 0.00 I 1 $0.310 1 1 50% 1 = I $0.00
ITEM I TOTAL - STORM DRAINAGE SDC
2. SANITARV SEWER - CITY
$823.52
A REIMBURSEMENT COST:
I NUMBER OF DFU's 1 x
I 29 I
B. IMPROVEMENT COST:
1 NUMBER OF DFU's 1
1 29 I
COST PER DFU
$24.04
x
$18.28
ITEM 2 TOTAL - CITY SANITARY SEWER SDC =, $1,227.28
3. TRANSPORTATION --
A REIMBURSEMENT COST:
I ADT TRJP RATE I x 1 NUMBER OF UNITS I x I COST PER TRJP x INEW TRIP F ACTORI
I 9.57 I I $18.30 I 1.00
B. IMPROVEMENT COST:
......1 ADT TRIP RATE I x 1 NUMBER OF UNITS 1 x I COST PER TRIP x INEW TRIP FACTORI
I 9.57 I I I $80.72 I 1.00
ITEM 3 TOTAL - TRANSPORT A nON SDC = , $947.62
4 SANITARV SEWER - MWMC
A REIMBURSEMENT COST:
INUMBER OF FEU's I x
I I
B, IMPROVEMENT COST:
INUMBER OF FEU's I x
I I I
ICOST PER FEU
I $82.03
ICOST PER FEU
I $865.31
MWMC CREDIT IF APPLICABLE (SEE REVERSE)
MWMC ADMINISTRATNE FEE
ITEM 4 TOTAL - MWMC SANITARY SEWER SDC = I
SUBTOTAL (ADD ITEMS I, 2, 3, & 4) ~ ,
5, ADMINISTRATIVE FEE:
1 SUBTOTAL x I ADM. FEE RATE I~
I $3.955.76 I 5% I
TOTAL SANITARY ADMINISTRATION FEE:
TOTAL TRANSPORTATION ADMINISTRATION FEE:
Matt Stouder
5/11 /2005
PREPARED BY
DATE
5622
I~
o
I~
II.Ll
f-<
en
(3
~
$823.52
11070
II
11091
$697.16
$530.12
11092
---.J
I
$175.13 1093
$772.49 1094
=
$82.03
1054
.
.
DRAINAGE HAl liRE UNIT (DFU) CALCULATION TABLE
NUMBER OF NEW FIXTURES x UNIT EQUIVALENT = DRAINAGE FIXTIJRE UNITS
(NOrE: FOR REMODELS, CALCULA rE ONLY THE NET ADDITIONAL FIXTURES)
NO. OF FIXTURES DRAINAGE
UNIT FIXTURE
FIXTURE TYPE NEW OLD EQUNALENT UNITS
IBAll1TUB 2 0 3 = 6
I DRINKING FOUNTAIN 0 0 1 = 0
I FLOOR DRAIN 0 0 3 = 0
I INTERCEPTORS FOR GREASE / OIL / SOLIDS / ETC. 0 0 3 = 0
I INTERCEPTORS FOR SAND / AUTO WASH / ETC. 0 0 6 = 0
I LAUNDRY TUB 1 0 2 = 2
ICLOTIIESWASHER / MOP SINK 1 0 3 = 3
ICLOll1ESWASHER - 3 OR MORE (EA) 0 0 6 = 0
IMOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0
IRECEPTOR FOR REFRIG / WATER STATION / ETC. 0 0 1 = 0
I RECEPTOR FOR COM. SINK / DISHWASHER / ETC. 0 0 3 = 0
!SHOWER. SINGLE STALL 1 0 2 = 2
ISHOWER. GANG (NUMBER OF HEADS) 0 0 2 = 0
ISINK: COMMERCiAuRESIDENTIAL KITCHEN 1 0 3 = 3
ISINK: COMMERCIAL BAR 0 0 2 = 0
I SINK: WASH BASIN/DOUBLE LA V A TORY 1 0 2 = 2
ISINK: SINGLE LAVATORY/RESIDENTIAL BAR 2 0 '1 = 2
I URINAL. STALL / WALL 0 0 5 = 0
ITOILET. PUBLIC INSTALLATION 0 0 6 = 0
ITOILET. PRlV A TE INST ALLA TION 3 0 3 = 9
MISCELLANEOUS DFU TYPE NUMBER OF EDU'S
20 = 0
TOTAL DRAINAGE FIXTURE UNITS 29
.EDU (Equivalent Dwellimt Unit) is a d.ischar~e equivalent to a single family dwellin~ unit (20 DFU's) set at 167 gallons per day .. ....-...
-- -.. ---.
MWMC CREDIT CALCULA TION TABLE: BASED ON COUNTY ASSESSED VALUE
YEAR
ANNEXED
BEFORE 1979
1979
1980
]981
1982
1983
1984
1985
1986
1987
1988
1989
199.
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
CREDIT RATFJ$I,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
II
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
2
2
1979
CREDIT FOR LAND (IF APPLICABLE)
VALUE / 1000 CREDIT RATE
$0.00 x $5,29
~ I
$0,00
CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION)
V AWE / 1000 CREDIT RATE
$0.00 x $5.29
o
TOTAL MWMC CREDIT
$0.00
=
225 Fifth Street
Springfield, Oregon 97477
541-72fi-3759 Phone
.
Wi-;"~'"-'"~,","'!""'~ .,','.,.,
1, "
',~
'I!II .. "
,~- -, -,. .' ...... ~'. --
...............,...
~ity of Springfield Official Receipt
.evelopment Services Department
Public Works Department
Job/Journal Number
COM2005-00507
COM2005-00507
COM2005-00507
,
COM2005-00507
COM2005-00507
COM2005-00507
J
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
"
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
CbM2005-00507
CbM2005-00507
COM2005-00507
CbM2005-00507
CbM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
COM2005-00507
"
Payments:
Type of Payment
CreditCard
;'1
'I
i
i
J
.
"
5/23/2005
;,
RECEIPT #:
1200500000000000655
Date: OS/23/2005
Description
Addressing Assignment
3 Baths One & Two Family
Furnace - up to 100,000 btu
Vent Fan
Exhaust Hoods
Dryer Vent
Gas Outlets 1-4
Gas Fireplace
Miscellaneous Mechanical
-Mechanical Issuance Fee-
+ 7% State Surcharge
+ 10% Administrative Fee
Plan Review Major - Planning
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
Curbcut - Additional Driveway
Addressing Assignment
Willamalane Single Family
Temp Power 200 amps or less
Building Permit
Paid By
RIVER VALLEY BUILDERS
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
djb 164439 In Person
Payment Total:
Page 1 of 1
8:53:39AM
Amount Due
31.00
306.00
12.00
18.00
9.00
6.00
4.00
15.00
27.00
10.00
101.83
145.47
103.00
80.00
80.00
(30.00)
823.52
697.16
530,12
175,13
772.49
82,03
865.31
10.00
135.28
62.51
40.00
31.00
1,000.00
50.00
1,007.65
$7,200.5U
Amount Paid
$7,200.50
$7,20U.50
f''; .'.;.... . \... ' ,.. ,.' . ,l( \., . . .,,, - " ~!: ."'" :>".~ .
t;f',<~<",' '.:'-', S~1Y Pf; ~.~UNC!F!BLB;,:oRl3f.{o~::::':.~'{l'-~ :;:
:!! ~
, .J"",, . ~
~ ":',: ~ ...;..",'::::';' ~
. FAX: (541)726-';v~0O:' l'<t~ ~W,
~o'\ ~o ~.~ t .,. :.<;!o..
"",,'iJ~00"
Date _\.,0",,0
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225 FIFfH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753
ELECTRICAL PERMIT APPLICATION
, City Job Number(Ol.c-l. ?..06 ~ - 0 c:> S; 0 I
}~ ~7':INrc/:A~~;~J-/
LEGAL DESCRIPTION
1702 I <7 t.{ "3
C>L(7~O
JOB DESCRIPTION
,eM P ?e>t.JclL
, Permits are non-transferable and expire if work is
,0 not started within 180 days of issuance or if work is
Suspended for 180 days.
~":~""f".", """.,i'" .,."... "".. .;,_...~..,. ":',""":':"'~"""_"':.:..' ..:.w'. "''"1.'''''''''''']
2. lfiJlftJ.,M,srqJ1~{ltST1f0l!/Z~PlYky.)
Electrical Contractor
Address
'-
/
/
City
Phone
Expiration Date
conSlr'2 Cntr, N ir
Expiration Ie
Signatur of Supervising Electrician
Owners Name .&eq ~-r ir ~
Address ;? tJ, 8i1 V $?-:s 2-
City~C/ A;'~rPhone 726-iJ"??rJ
OWNER INST ALLA nON
The installation is being mad prope
is not inten~e, Ie or rent.
77:e:
Inspection Request: 726-3769
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
$106,00
$ 19.00
$50.00
, !B:~tt~,~r~m~s)i~jE.~~ci~~~~~i~B;~p1Y.~~tf~i\.s;~i~;(g'c',.'ti';n:
. ov' ,~fr~ :'30Jpfe'dDylh'!C)'regdlftJliliW" '.. 'c.' ,,'" ",
tL ~,t200;Amps,orl1ess Those rules are set forth $ 63.00
in OiiOI9Amp,ctb'ilOd ~Slugh OAR 952.001. $ 75.00
009Cl!a,jOA'rli'j\i't'of6ob1iMpsPies of the rules by $125,00
caMing.4\~sqbfJ.'&10 ~~: the telepnone $163,00
nUI()~,\lllfJOJIJ&O~ity Noti;i~. $375.00
RecoWNJ!\l(ljAi - .2344). $ 50.00
r "'~,~--,""''r''''''', '~,::>O.~, ',<,~, .:'; ~/~,' ~';~';\,<:^ ",,1<-';' ",...li<~,:-.;r.j:...,~".~;.,-.;: :'~:~,- :,',...'ll"1i.tkf~,'i...,,"i, ...,:t(:i>i,,'
c. ~~1.'e~ pOJ:"ary..'S~~~cesor.~lfee~~!s-..r/', ~;';'i',;'f.i;;'. ;~,...:1(1,'" -"~),..I'?:~.<~~~
Installation, Alteration or Relocation
200 Amps or less
20 I Amps to 400 Amps
40 I Amps to 600 Amps
I $ 50.00
$ 69.00
$100.00
s-o
Over 600 Amps or 1000 Volts see "B" above.
D. "rJ3.f~!i~~~G'it~~i~r'.:::~:~.lj:t.~?,~~~;::';~,';~~'~'j.:t~,
,
,
"
New Alteration or Extension Per Panel
, One Circuit
Each Addi'iiodli eircuit or with
ServiceorJFeede.tl~ermiL'HALL E'm"'~ '" l$H 3'WOOOfi
., I..... I ... dOl,' V 1\1 IlIL II 1: l\
r .~,f.~~rn~'j:Jf\tPi~ii#9;'fl~ml""I\I' J' ,"', ."'1)
E. ,:,Miscfllaneous.,(Ser.v,,,,.',celfeeder b~~~u,.cIuijed)~Each ',Installa bOil,,'
.......,,""..V'tC..\)C.u.~~1-\,'. bll::l~IFFGH'" .. .',. .',",
Pump o~liJJ'gJt~cPn DAY PERIOD, $ 50.00
Sign/Outline Lighting $ 50.00
Limited EnergylResidential $ 25.00
Limited Energy/Commercial $ 45.00
$ 43.00
Minimum Electric Permit Inspection Fee is 545.00 + Surcharges
4 risiJBfofAibF~'OY'E;R,>,:itl/;""t't:i;' i .'1
. I.:' ,l-'Jr, ";""';'5';\,;;;:;.::,' <,<:'- ", .,,~:/i,".;~::~r;~~'(; ~~'~'~?j
'5:0
'3SD
~
S;B~
7% State Surcharge
10% Administrative Fee
TOTAL
Shared Drive(T:)/Building FonnslElectrical Permit Application 1-03.doc