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Home My WebLink AboutPermit Building 2004-8-6 Status Issued - CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-00929 ISSUED: 08/06/2004 APPLIED: 07/27/2004 EXPIRES: 02/06/2005 VALUE: $ 15,000.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 1270 39th St ASSESSOR'S PARCEL NO.: 1702304304001 Springfield TYPE OF WORK: Manufactured Home on Private Lot TYPE OF USE: New Residential PROJECT DESCRIPTION: Manufactured Home Owner: JONES FAMILY TRUST Address: 6022 THURSTON RD SPRINGFIELD OR 97478 Contractor License BEAR MOUNTAIN ELECTRIC LLC 136298 JERRY OTT 69455 DOUGLAS LEO SCHIRMER 93671 I B~~~INFORMATIONI # of Units: 1 ~ ~ ~'\~~tories: 1 Lot Size: Primary Occupancy Group: Rr~~ ((~~ &..~'tght of Structure Sq Ft 1st Floor: Secondary Occupancy Group: ::v\.'::~~S <N\)~ Type of Heat: orced Air Electric Sq Ft 2nd Floor: Primary Construction):ype S'0~\)~'V'N ~~~ Water Type: Electric Sq Ft Basement: Secondary constr~~'b-~~: '0~ {o ~ Range Type: Electric Sq Ft Garage/Carport # ofBedrooms:~~ S ((<(;. ~~\) \) \)~ ~\). Energy Path: Sq t,t\Other: ,\0 '0\)~ ~~<(;. ~ ((<(;. Sprinkled Building: n/a. ~<c?~'\ Load: ,\'\. , ~'V. -:--Y ,,-<.'6 J' ~('\~\' . '('~\)~~\<o\) I DEVELOPMENT INFORMATIO~rt -<.eO-<.e~~e CO~~~\)\) ~i ~~ ~o\ \ N ~e J.eCO ,\>-<(0. '1J ~UlRED PARKING . 0-<.10 0. '0 e -<. 0 e -<'-r,cJ>.~e 30.00 Overlay Dist:, ~, R\.e ,,\,\,-0C;) 0~'00 0' ~ ~e~n:~~o~ 2 20.00 # Street Trees~<d:s '0-0.0 ~e'\' \) ~,\o SfS K\e \.e ~li~icapped: 13.00 Paved D%\:-e~~':--'6 (je-<" ,\)\)\ \<' ~~~.~ .~'\ ~~~J;Dpact: 30.00 % of Lot ~~r~prf ~\)\)\ 0'0\''0' 1~~ \)~'\ rl!:>t>. 0.00 o~'\V 9:J'i -<."'0-'\ ,<p\.e'\' e~o ,'!:>'!:>'?; ~ ^~<(o. _ I['V- , "G .' 0'\ p;"\) I PUBLIC IMPROV~~ ~o-<' ~~-<.\CO"! G I ^v-~ (jeSidewalk Type: rave v Yes Downspouts/Drains: Storm drainage to existing ditch on Kathryn. Contractor Type Electrical Manuf Home Inst Plumbing Front yard Setback: Side 1 Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Improvements: Storm Sewer Available: Special Instruction: Notes: I CONTRACTOR INFORMATION I Expiration Date 08/06/2005 09/26/2004 09/02/2004 Phone 541-953-6747 541-935-2696 541-485-1949 6,100 1,056 To Storm Sewer Pa2e 1 of3 _ SeRJ,N~E'I:m.,Q 1 ! ! Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Description Tvpe of Construction Fee Description Plan Review Residential + 10% Administrative Fee + 7% State Surcharge Addressing Assignment Annexed 1979 or Before Manuf Home State Issuance Manufactured Home Conn - Plmb Manufactured Home Feeder Manufactured Home Placement Manufactured Home Service Plan Review Major - Planning Sanitary Sewer - 1st 50 Feet Sanitary Sewer - Improvement Sanitary Sewer - Reimbursement SDC MWMC Administration SDC MWMC Improvement SDC MWMC Reimbursement SDC Sanitary/Storm Admin SDC Transpo Admin SDC Transpo Improvement SDC Transpo Reimbursement Storm Drainage Impervious Area Storm Sewer - 1st 50 Feet Water Line - 1st 50 Feet Willamalane Manuf Home Private Total Amount Paid Initial Review 07/26/2004 Planninl! Review 07/27/2004 I Valuation Description I $ Per SqFt or multiplier Square Footage or Bid Amount Total Value of Project ~ Amount Paid Date Paid $29.25 $44.00 $30.80 $31.00 $-57.24 $30.00 $45.00 $50.00 $160.00 $50.00 $103.00 $45.00 $365.60 $480.80 $10.00 $865.31 $82.03 $95.78 $65.69 $772.49 $175.13 $535.37 $45.00 $45.00 $1,000.00 7/22/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 8/6/04 $5,099.01 I Plan Reviews I 07/27/2004 APP LLH 08/05/2004 APP TAJ Pal!e 2 of 3 CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-00929 ISSUED: 08/06/2004 APPLIED: 07/27/2004 EXPIRES: 02/06/2005 VALUE: $ 15,000.00 Value Date Calculated Receipt Number 1200400000000001125 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 2200400000000001016 Held for address assignment by Don Moore Status Issued CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-00929 ISSUED: 08/06/2004 APPLIED: 07/27/2004 EXPIRES: 02/06/2005 VALUE: $ 15,000.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Public Works Review 07/27/2004 07/29/2004 APP MS 8/2/2004 - Applicant came to front counter. Sanitary will be routed to the existing tap on 39th Street. In the event the existing tap is being used by the house on the adjacent parcel, the applicant agreed to fiU out an encroachment permit and tap the main line in 39th. - MAS 07/27/2004 08/06/2004 APP DLM Structural Review 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. I Reouired Insoections I Ufer Electrical Ground: InstaU ground rod at footing and caU for inspection in conjunction with footing and/or foundation inspection. Manuf Home Set Up: When instaUation of aU piers or stands is complete. Final ManufHome Set Up: After aU required inspections are requested and approved and porches, skirting, decks, venting, street address numbers, trees, driveway, etc. have been instaUed. Final Building: After aU required inspections have been requested and approved and the building is complete. 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. ManufHome Plumbing: After home has been connected to water and sewer. MH Electric: When blocking, setup and plumbing inspections have been approved and the home is connected to the panel. MH Service: Approval required prior to utility company energizing service. Footing: After trenches are excavated. By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that aU information hereon is true and correct, and I further certify that any and aU 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 Coinmunity 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 aU times during construction. '~~~vg~,'v~ Ow~er or Contractors S!g~ - 6 A- /.)6 O~ Date Pae;e 3 of 3 ::-'c9(' <s> i' 225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 · F~: .,41) ~3689 ">0/ :<I'<I'v6 Or.' ~ &9, '?; ELECTRICAL PERMIT APPLICATION Z><S>Q' , _ <~. v/,;,,<s>~i/<s>O' f'h fl f\fYf " /X'I ' &. 0' -? City Job Number \V nct\ U",l_ It" .Cl: )1-11.[..1 Date 06.... C) '=::> - c 4- (9,,><:>1, ~ ~<S>('/;t<l' 0 _ \ ;-1 v",<s> (' /, &;; 1. ?~Q9~i'rfFfi?ifk'i#f.ff!Jji?ifrt!.~{:', ". 3.~:!;iiMifti:~~f~# ~,~H~t!:A_""~>' ~ > '(f,;.i".;,.i"2t;:;~~;.S",""':;' VL"\O 8C\-m, Sb LEGAL DESCRIPTION \ l O~ '"50~ ~ ()4cD.\ ~lftt'>kf'-.'-?\~;?<('; '. ')' '~<,:,.'}:: :+::~i~::.?-1"!~,'i< }N\',. .;,. '~'.:-\J;\~:,1~<r '.:.;:~i/": -', ,.>. . .:_. .' _/~7':~-\~'; ,";:'. .~.t:.Y~'D;~~-~~At(:.:" ..... ,,:,'- <-,:',':__ ':'1':"~':'T:>:::!:~.~-:~<':i<jf\. ~ ~:)~".""':0:~:.{~,;::;..,,<::y~:,~~:!i:~:/:;-:;" :: ,~\~::.,::;:<~,;:~.~: "> 'i '-',.:. '::; ,;.,,;. .. 2. t:fJl!J:!1!~SI8!!:,l!t.f!lI:f~E~!ti PItt};, B.(.~e,t,;!~~E~~F'eeders-;&nlt!~n~~~?lf,~tl~t~~'~;?&~i~;~I3.~,i?:~t~~~::':i:....' Electrical Contractor Bf'Ar &u,^k~ ~k,<!.. 200 Amps or less $ 63.00 Il ,9 Q 201 Amps to 400 Amps $ 75.00 Address r'DDeJY /1.. 401 Amps to 600 Amps $125.00 ~-.~ 601 Amps to 1000 Amps $163.00 CityertS&AJe(( 9'lliUPhone ?!!s.1~ Over 1000 AmpsNolts $375,00 $v ~ #- '\->~~ Reconnect Only $ 50.00 f)~~<0, ~y. Supervisor License Numb~ ~~ c.%'ff~e,~'rary~er.;~~ ~~J;r~~~{"~~Y~Ff~!:~~J;~r, .S~~~~&~ ~.~ Expiration ~~.~.t- ';,,~cr-()t1 Installation, Alter~~~~~tion ~~ ~y"''0''iy'''<;J ifrt}.\:)'V. 200 Amps or 1#':e~O<::-0 f00' ~~~~:~ $ 50.00 constr~~~~.}-'\) 19tJ( 20lAmp~~b~~~~Q)~ ,s,0fOvt, $69,00 ~~ ~~<;J 401 A~~~~~~ ~0i\ ~O(:\'('o<::- $100.00 Expiration ~ifl~~\ - b -C>~ ~~\~~~~~~~~;:~r~~~~:'above~ Sil;)O suw~e is' cElectriCian R-a-;;c , .. ,~\X)IU')~;""0',~;;,\' . <v~ ~.'" .!:.)~. .,~~g:o"'P~V!J rs ~"- * \~&"c;Wr~ o~x~'ri~~er Panel ,~~~v~~i~ 0~0<\' ~00;O ';:)~~ $ 43.00 v ' ~o~ ~~~@B;grou)t or with Owne"Name '&ooelt ,\~Qj)~~:;~~:;~".. ....,...$.3::,...?&.. Address \ a() 1:) _ _ IN.lr~ To (\ \<d E. :'{;~E:~.l~neo~;~~~b:i,~~!f~~~e~.J1o.! ~~ld~1~cf)=~,~,f~,,~P~:t~ll~t~~~~, City~{l\~'e1dPhone ~1 \ '<f11 JOB DESCRIPTION- \. ~(\L(\ \..J _ ~~o_ Permits are non-trans hie and expire if work is not started within 180 ays of issuance or if work is Suspended for 180 days. OWNER INST ALLA nON The installation is being made on property I own which is not intended for sale, lease or rent. Owners Signature: T_____...:__ n__................ --...,~ .,.,t:.n Service Included A. ;~~~~~'~~~(~~'ri'fi~(:Ysirigl~'~i"}\,ifl~~F~rri" :,:~~r; 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 \00.. cO Pump or irrigation Sign/Outline Lighting Limited Energy/Residential Limited Energy/Commercial $ 50.00 $ 50.00 $ 25.00 $ 45.00 Minimum Electric Permit Inspection Fee is $45.00 + Surcharges 4. ~r~~~3ii~1s;;~~~8-,~;21;i;';,i;;:::.,;;;;,~:t::~cr';:"jlf). (j) fl.OO tC).OO \iL~. CO "'10 State Surcharge 10% Administrative Fee TOT AT. 225 FIFTH STREET SPRINGFIELD, OR 97477 (541) 726-3753 FAX (541) 726-3689 MANUFACTURED HOME LAND USE AGREEMENT As required by the City of Springfield Development Code, I agree that with the approval of the attached permits, one of the following manufactured homes will be placed at /2-'7 0 ~ '1 ~ _,\r, , Springfield, Oregon, City Job Number ('.{))U 2~f)ttf -tJC1!/2.' - ' - . L Type I Manufactured Home. A multi-sectional (double wide or wider) unit with an enclosed floor area of not less than 1,000 square feet, that has a nominal roof pitch of 3 feet in height for each 12 feet in width, that has no bare metal siding or roofing, and that has been certified by the manufacturer to have an exterior thermal envelope meeting performance standards which reduce heat loss to levels equivalent to the perfonnance standards required of single family dwellings constructed under the State Specialty Codes. Type II Manufactured Home. A unit of not less than 12 feet in width with an enclosed floor area of not less than 500 square feet; that has a nominal roof pitch of2 feet in height for each 12 feet in width and that has no bare metal siding or roofmg. The manufactured home shall be placed on an excavated and back-filled foundation not to exceed 6 percent slope within 10 feet of the pei-imeter enclosure. The perimeter foundation wall surrounding the home shall be constructed of stone, brick or other masonry materials, and with no more than 24 inches of the enclosing material exposed above grade. I further agree to meet all land use and City Code requirements of the above mentioned parcel within 60 days of the date of Issuance of the manufactured home set up permit. These requirements may include, but are not limited to the items listed below. Specific land use requirements regarding your parcel are noted on your approved set up plans andlor permit and your partition approval if applicable: . Street Trees . Paving Driveway . Minimum 32 square foot storage structure . Completion of partition approval . Removal of any existing structures as noted on your partition approval . Signing and recording of any required partition, easement, improvement agreements, etc. . Fmallot grading . City Sidewalk and curbcut installation . Any outside agency approval as required Le., Division of State Land approval. )< ~=; Q~=le'e ilie aoove men';oned land me:qu;:e:~6 d Lj Owner Signature C Date I - Contractor Signature Date $480.80 1091 $365.60 " 1092 x NEW TRIP FACTOR II 1.00 I. $175.13 1093 x I NEW TRIP FACTOR I '1.00 $772.49 1094 CITY OF SPRINGFIELD SYSTEMS DEVELOPMEN , JOURNAL OR JOB NUMBER: COM2004-00929 NAME OR COMPANY: Bronell Jones ' LOCATION: 1270 39th Street TAX LOT NUMBER: 17023043 Tax Lot 04001 DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE NEW DWELLING UNITS 1 BUILDING SIZE (SF . 0 ,ORKSHEET LOT SIZE (SF): 6099 1, STORM DRAINAGE.. DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S,F." x COST PER S,F, CHARGE I . 1247,00 $0,310' I . $386,57 I RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS IMPERVIOUS S,F, x I COST PER S:F. I ~x DISCOUNT RATE I 0,00. I $0.310' I 50% = I DISCOUNT $0,00 . ITEM 1 TOTAL - STORM DRAINAGE SDC 2, SANITARY SEWER - CITY A REIMBURSEMENT COST: I NUMBER OF DFU's x I COST PER DFU I 20 .1 $24,04 B. IMPROVEMENT COST: NUMBER OF DFU's x I. 20 I $18,28 ITEM 2 TOTAL - CITY SANITARY SEWER SDC 3, TRANSPORTATION A REIMBURSEMENT COST: ' ADT TRIP RATE x , 9,57 $386.57 1 $386.57 =1 $846.40 I NUMBER-OF UNITS x I I 1 I COST PER TRIP $18,30 B. IMPROVEMENT COST: ADT TRIP RATE x 9,57 I NUMBER OF UNITS I 1 x I... COST PER TRIp I $80,72 = I $947.62 " , ITEM 3 TOTAL - TRANSPORTATION SDC 4, SANITARY SEWER - MWMC A REIMBURSEMENT COST: NUMBER OF FEU's x 1 " ,t ICOST PER FEU. I $82.03 = $82.03 B. IMPROVEMENT COST: INUMBER OF FEU's . x I 1 . ICOST PER FEU I $865.31 $865.31 ($57.24) $10.00 MWMC CREDIT IF APPLICABLE (SEE REVERSE,) MWMC ADMINIS.TRA1WE FEE ITEM 4 TOTAL ~ MWMC SANITARY SEWER SDC =, SUBTOTAL (~DITEMS 1,2,3, & 4) = 1 5, ADMINISTRATIVE FEE: SUBTOTAL x I ADM, FEE RATE $3,080.69 I 5% TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: $900.10 $3,080.69 CHARGE $154.03 1 I 87,09 $66,94 Matt Stouder =, $3,234.72 7/30/2004 TOTAL SDC CHARGES PREPARED BY DATE [fJ ~ Cl o U ~ ~ E-< [fJ ..... o ~ 1070 , 1054 lOSS 1054 11056 . I 1079 . 1078 DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVALENT = DRAINAGE FIXTURE UNITS (NOTE: FOR REMODELS, CALCULATE ONLY THE NET ADDITIONAL FIXTURES) NO. OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE TYPE NEW OLD EQUIVALENT UNITS I BATHTUB 2 0 3 = 6 IDRINKlNG FOUNTAIN 0 0 1 = 0 FLOOR DRAIN 0 0 3 = 0 INTERCEPTORS FOR GREASE I OIL I SOLIDS I ETC. 0 0 3 = 0 IINTERCEPTORS FOR SAND I AUTO WASH I ETC. 0 0 6 = 0 I LAUNDRY TUB 0 0 2 = 0 ICLOTHESWASHER/MOP SINK 1 0 3 = 3 ICLOTHESW ASHER - 3 OR MORE (EA) 0 0 6 = 0 'MOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 I RECEPTOR FORREFRIG I WATER STATION IETC. 0 0 1 = 0 I RECEPTOR FOR COM. SINK I DISHWASHER I ETC. 0 0 3 = 0 ISHOWER, SINGLE STALL 0 0 2 = 0 I SHOWER, GANG (NUMBER OF HEADS) 0 0 2 = 0 I SINK: COMMERCIAL/RESIDENTIAL KITCHEN 1 0 3 = 3 I SINK: COMMERCIAL BAR 0 0 2 = 0 SINK: WASH BASIN/DOUBLE LAVATORY 0 0 2 = 0 SINK: SINGLE LAVATORY/RESIDENTIAL BAR 2 0 1 = 2 URINAL, STALL I WALL 0 0 5 = 0 TOILET, PUBLIC INSTALLATION 0 0 6 = 0 ,TOILET, PRIVATE INSTALLATION 2 0 3 = 6 MISCELLANEOUS DFU TYPE NUMBER OF EDU'S 20 = 0 TOTAL DRAINAGE FIXTURE UNITS 20 *EDU (Equivalent Dwelling Unit) is a discharge equivalent to a single family dwelling unit (20 l2..~s) set at 167 gallons per day MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 CREDIT RATE/$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 IS LAND ELGIBLE FOR ANNEXATION CREDIT? (Enter 1 for Yes, 2 for No) IS IMPROVEMENT ELGIBLE FOR ANNEX, CREDIT? (Enter 1 for Yes, 2 for No) BASE YEAR CREDIT FOR LAND (IF APPLICABLE) VALUE I ] 000 CREDIT RATE $]0.82 x $5,29 =1 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) V ALOE 11000 CREDIT RATE $0,00 x $5.29 TOTAL MWMC CREDIT = o 1979 $57.24 o $57,24 225 F~fth Street .'Springfield, Oregon 97477 541-726-3759 Phone $Ph,'NG~IE LD~,''',!O-'~ !!"....... ~JD1t ~_.. ruy of Springfield Official Receipt ,velopment Services Department Public Works Department 1,..; Job/Journal Number COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 COM2004-00929 Payments: Type of Payment Check 8/612004 RECEIPT #: 2200400000000001016 Date: 08/06/2004 Description Addressing Assignment Willamalane ManufHome Private Manufactured Home Feeder Manufactured Home Service Manufactured Home Placement Manuf Home State Issuance Sanitary Sewer - 1st 50 Feet Water Line - 1st 50 Feet Storm Sewer - 1st 50 Feet Manufactured Home Conn - Plmb + 7% State Surcharge + 10% Administrative Fee 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 Annexed 1979 or Before Plan Review Major - Planning Paid By BRONELL B. JONES Item Total: Check Number Authorization Received By Batch Number Number How Received jmp 7386 In Person Payment Total: Page I of I 1:41:38PM Amount Due 31.00 1,000.00 50.00 50.00 160.00 30.00 45.00 45.00 45.00 45.00 30.80 44.00 535.37 480.80 365.60 175.13 772.49 82.03 865.31 10.00 95.78 65.69 (57.24) 103,00 $5,069.76 Amount Paid $5,069.76 $5,069.76