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Home My WebLink AboutPermit Building 2004-5-28 . CITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2004-00369 ISSUED: OS/28/2004 APPLIED: 04/02/2004 EXPIRES: 11/28/2004 VALUE: $ 220,878.00 '" Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 114 75th St ASSESSOR'S PARCEL NO.: 1702354100900 Springfield TYPE OF WORK: Single Family Residence TYPE OF USE: PROJECT DESCRIPTION: SFR - Crossway Estates lot 9 Owner: PHILIP THOMAS & GLORY T Address: PO BOX 21443 EUGENE OR 97402 I CONTRACTOR INFORMATION I Contractor Type General Electrical Mechanical Plumbing Contractor GORDON BRET EVANS L YNNS ELECTRIC MICHAEL GRIFFIN DONALD CLEWIS License 102721 102316 150189 33076 I BUILDING INFORMATION. ;~ # of Units: 1 # of Stories: 2 Pri~ary Occupancy Group: R-3 Height of Structure 27.50 Secondary Occupancy Group: U-l !Ie ofMfdb Forced Air Gas Primary ConstructionllWPENTION: <VNt9on law ram" Gas Secondary Constructi~HtiypetJles adopted by the ~ ~I~I~ Gas # of Bedrooms: Notification Center. Those r~N9 .~i. Path 1 in OAR 952-001-0010througB~&iI~<<ll't1tfiitg: n/a , \ 3Lcl....I- ....rloc>l'\fthA rlllp!~ bv UV;:7U. IlJu II ....., _~... .. 1_ calling the center.' ~It0ItM~INFORMATION I number for the OregonUiihty NotlTlCClLlUII Cenlf3rdo 1-800-33~'Ny Dist: '" , 12.50 # Street Trees Rqd: 5.00 Paved Drive Rqd: 28.00 % of Lot Coverage: 22.50 Front yard Setback: Side 1 Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: v I PUBLIC IMPROVEMENTS I Sidewalk Type: Curbside 5' Fully Improved NOTICE. ' Downspouts/Drains: THIS PERMIT SHALL EXPIRE IF THE WOR~ AUTHORIZED UNDER THIS PERMIT IS NO COMMENCED OR IS ABANDONED FOR ANY 180 DAY PERIOD. Street Improvements: Storm Sewer Available: Special Instruction: Notes: Pal!e 1 of 4 New Residential Expiration Date 1012012004 10/14/2007 01/23/2005 06110/2007 Phone 541-746-4803 541-726-7895 541-942-8339 541-688-1931 Lot Size: 6,000 Sq Ft 1st Floor: 1,486 Sq Ft 2nd Floor: 794 Sq Ft Basement: Sq Ft Garage/Carport 420 Sq Ft Other: Occupant Load: 2 Yes 31.70 REQUIRED PARKING Total: 2 Handicapped: Compact: . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-00369 ISSUED: OS/28/2004 . APPLIED: 04/02/2004 EXPIRES: 11/28/2004 VALUE: $ 220,878.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line I V aluation DescriD~ion I , $ Per Sq Ft Square Footage Description Tvpe of Construction or multiplier or Bid Amount Value Date Calculated Dwellinl!s V Wood Frame $92.40 2,280:00 $210,672.00 04/02/2004 Garal!e Garal!e $24.30 420.00 $10,206.00 04/02/2004 Total Value of Project $220,878.00 ~ Fee Description Amount Paid Date Paid Receipt Number Plan Review Residential $623.29 4/2/04 2200400000000000313 -Mechanical Issuance Fee- $10.00 5/28/04 1200400000000000828 + 10% Administrative Fee $156.69 5/28/04 1200400000000000828 + 7% State Surcharge $109.68 5/28/04 1200400000000000828 3 Baths One & Two Family $306.00 5/28/04 1200400000000000828 Addressing Assignment $31.00 5/28/04 1200400000000000828 Annexed 1980 $-144.10 5/28/04 1200400000000000828 Appliance Vent $6.00 5/28/04 1200400000000000828 Building Permit $958.90 5/28/04 1200400000000000828 Copies - Ea Addtl @ 50 Cnts Ea $8.00 5/28/04 1200400000000000828 Copy 6th @ 75 cents $0.75 5/28/04 1200400000000000828 Curbcut Permit $75.00 5/28/04 1200400000000000828 Dryer Vent $6.00 5/28/04 1200400000000000828 Exhaust Hoods $9.00 5/28/04 1200400000000000828 Furnace - up to 100,000 btu $12.00 5/28/04 1200400000000000828 Gas Fireplace $15.00 5/28/04 1200400000000000828 Gas Outlets 1-4 $4.00 5/28/04 1200400000000000828 Plan Review - Planning $71.00 5/28/04 1200400000000000828 Plan ReviewIResidential Hourly $135.00 5/28/04 1200400000000000828 PW Mult Disc - 2nd Permit $-30.00 5/28/04 1200400000000000828 Residence Wiring 1000 Sq Ft $106.00 5/28/04 1200400000000000828 Residence Wiring Ea Addtl 500 $76.00 5/28/04 1200400000000000828 Sanitary Sewer - Improvement $499.09 5/28/04 1200400000000000828 Sanitary Sewer - Reimbursement $656.56 5/28/04 1200400000000000828 SDC MWMC Administration $10.00 5/28/04 1200400000000000828 SDC MWMC Improvement $214.23 5/28/04 1200400000000000828 SDC MWMC Reimbursement $314.63 5/28/04 1200400000000000828 SDC Sanitary/Storm Admin $107.34 5/28/04 1200400000000000828 SDC Transpo Admin $50.97 5/28/04 1200400000000000828 SDC Transpo Improvement $727.42 5/28/04 1200400000000000828 SDC Transpo Reimbursement $164.89 5/28/04 1200400000000000828 Sidewalk Permit $75.00 5/28/04 1200400000000000828 Storm Drainage Impervious Area $723.41 5/28/04 1200400000000000828 Temp Power 200 amps or less $50.00 5/28/04 1200400000000000828 Vent Fan $18.00 5/28/04 1200400000000000828 Pal!e 2 of 4 Building/Combination Permit PERMIT NO: COM2004-00369 ISSUED: OS/28/2004 APPLIED: 04/0212004 EXPIRES: 11/28/2004 VALUE: $ 220,878.00 . ~~.~~J~B~!"!;~j: >>, ,,', .~ ~ 0:; ;' Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Willamalane Single Family $1,000.00 5/28/04 Total Amount Paid $7,156.75 I Plan Reviews I Initial Review 04/05/2004 04/05/2004 APP LLH Plan nine: Review 04/05/2004 04/17/2004 APP TAJ Public Works Review 04/07/2004 04/13/2004 APP VRJ Structural Review 04/05/2004 04/21/2004 WE DLM Structural Review 05/07/2004 OS/25/2004 APP DLM . CITY OF SPRINGFIELD 1200400000000000828 Called contractor to verify storm, contractor plans to take storm to curb and gutter. Sent letter requesting additional informatioin and clarification to contractor and designer. 4/21/04 dim 'Met w/ designer to review the issues involved in the above request 4/27/04 dim Designer submitted response to requested information including engineering. Received lateral bracig cales and revised truss layout with replacement drawings for sh. 3 thru 6. 5/12/2004 dim 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. 1 Sidewalk - Curbside: After forms are erected but prior to placement of concrete. 2 Curbcut - Standard: After forms are erected but prior to placement of concrete. 27 Final Gas: When all gas work is complete. 28 Final Mechanical: When all mechanical work is complete. 29 Temporary Electric: Approval required prior to Utility Company energizing pole. 30 Rough Electric: Prior to Cover 31 Electric Service: Approval required prior to utility company energizing service. 32 Final Electric: When all electrical work is complete. 3 Ufer Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing and/or foundation inspection. 4 Footing: After trenches are excavated. 5 Foundation: After forms are erected but prior to concrete placement. 6 Post and Beam: Prior to floor insulation or decking. 7 Floor 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 Ceiling Insulation: Prior to cover. 12 Drywall: Prior to taping. Pae:e 3 of 4 . CITY OF SPRINGFIELD. Building/Combination Permit PERMIT NO: COM2004-00369 ISSUED: OS/28/2004 APPLIED: 04/02/2004 EXPIRES: 11/28/2004 VALUE: $ 220,878.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line 13 Hold Downs Installed: Special Inspection performed prior to placement of concrete. Provide report to City Building Inspector. 14 Final Building: After all required inspections have been requested and approved and the building is complete. 15 Underfloor Plumbing: Prior to insulation or decking. 16 Underfloor Drain: Prior to cover or placement of concrete. 17 Rough Plumbing: Prior to cover and including required testing. 18 Shower Pan. Prior to covering and including required testing. 19 Water Line: Prior to filling trench and including required testing. 20 Sanitary Sewer Line: Prior to filling trench and including required testing. 21 Storm Sewer Line: Prior to filling trench. 22 Final Plumbing: When all plumbing work is complete. 23 Underfloor Mechanical. Prior to insulation or decking and including required testing. , 24 Rough Gas: After line is installed and required testing and capped if not attached to an appliance. 25 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. 26 Rough Mechanical: Prior to Cover 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. ;J~-/~ ~ ~..' r ~ .2 Y -c:J'-7' Owner or Contractors Signature Date Page 4 of 4 225 Fifth Street ~ . Spr~ngfield, gfi~on 97477 541-726-3~fft1'Phone // //" RECEIPT #: Job/Journal Number COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 h, COM2004-00369 '.~ " COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 i~~,COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 COM2004-00369 Payments: ", Type of Payment Paid By Check 5/28/2004 ~j:. ,~~.!~D::o' '........"., '~.". ~I'" . t I '>; ~ ":~~.~, 'i .,T....-"-'''''-'''-....:I\'-1''''..\.,.~.~r. '-f"'."".",,} City of Springfield Official Receipt 'elopment Services Department Public Works Department 1200400000000000828 Date: OS/28/2004 Description Addressing Assignment Willamalane Single Family Temp Power 200 amps or less Residence Wiring 1000 Sq Ft Sidewalk Permit Curbcut Permit PW Mult Disc - 2nd Permit 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 1980 Plan Review - Planning Building Permit 3 Baths One & Two Family Furnace - up to 100,000 btu Vent Fan Appliance Vent Exhaust Hoods Dryer Vent Gas Outlets 1-4 Gas Fireplace -Mechanical Issuance Fee- Residence Wiring Ea Addtl 500 Copy 6th @ 75 cents Copies - Ea Addtl @.s0 Cnts Ea Plan ReviewlResidential Hourly + 7% State Surcharge + 10% Administrative Fee Item Total: Check Number Authorization Received By Batch Number Number How Received TOM PHILIP djb 1541 In Person Payment Total: Page 1 of 1 1:18:05PM Amount Due 31.00 1,000.00 50.00 106.00 75.00 75.00 (30.00) 723.41 656.56 499.09 164.89 727.42 314.63 214.23 10.00 107.34 50.97 (144.1 0) 71.00 958.90 306.00 12.00 18.00 6.00 9.00 6.00 4.00 15.00 10.00 76.00 0.75 8.00 135.00 109.68 156.69 $6,533.46 Amount Paid $6,533.46 $6,533.46 ., . P.~'Willamalane n~__ . ~ '- j. Park & Recreation Oistrict Job. No. .LUl1112DD4 .~ ~. SYSTEM DEVELOPMENT CHARGE WORKSHEET NAME: '\\~ \)\\~Jjj) PHONE: . %~ 4\G\c{ ADDRESS:_S~5ld5Qidt"\~ STATE: DR- ZIP:Q14S5 .LOCA TIQN OF PROPOSED BUILDING SITE: Street Address: . \t L\ ,",~th S\reL.-t Plat Name: .. (!mSS~ E'3l_ Tax Lot Number. \10'l.~rr:P..(fJ 1~ 'DEVELOPMENT TYPe: (Checkappropciate dwelling(s). SOC calculations and dwelling t , ~e definitions are on t~e back.) A SinQle-Family l)etached. . c,l, Single 'Family home 'NO. OF UNITS Manufactured home not in a park ' \ ,X $1,000 per unit.::: ,$' loCO.CO, 8. .Sinale-Familv Attached~ NO. OF UNITS X $924 per unit ,:::. $ C. Multi-Familv Aoiutment NO. OF UNITS ,X .$692 per unit - $ l?~ Mant1faGfl!q~0 H0me Part NO. OF UNITS , WILLAMALANE SDC X $699 per unit '= $ $ \C'CO'4C"O II 2. SDC CREDIT' (if applicable) SOG-payer must furnish proof of Vlillarnalane Credit approval. See SDC yredil Worksheet. $ 3~ TOTAL W1LLAMALANE NET SDC ASSESSED , ~f SOC reduced for Credit) \l ~ J{( \f.\{) U) Development Se~partment City of Springfield ' 5 I Z~I Date $ (Oa) ,00 O~ . ,..'.., CITY OF SPRINGFIELD SYSTEMSDEVElOPMEAoRKSHEET JOURNAL OR JOB NUMBER: com2004-00369 NAME OR COMPANY: Tom Philip LOCATION: 114 75th Street ."" TAX LOT NUMBER: 17023541 tl900 DEVELOPMENT TYPE: SINGLE F AMIL Y RESIDENCE NEW DWELLING UNITS 1 BUILDING SIZE (SF: o LOT SIZE (SF): 1. STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. x COST PER S.F. CHARGE I 2494.50 $0.290 = $723.41 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS IMPERVIOUS S.F. x. COST PER S.F. x DISCOUNT RATE I DISCOUNT 0.00 $0.290 50% $0.00 ITEM 1 TOTAL - STORM DRAINAGE SDC $723.41 I 2. SANITARY SEWER - CITY A. REIMBURSEMENT COST: I NUMBER OF DFU's x I COST PER DFU I 29 ' I $22.64 B. IMPROVEMENT COST: I NUMBER OF DFU's I 29 x I COST PER DFU I $17.21 ITEM 2 TOTAL - CITY SANITARY SEWER SDC =, 3. TRANSPORTATION A. REIMBURSEMENT COST: ADT TRIP RATE x. NUMBER OF UNITS x 1 COST PER TRIP 9.57 1 1$17.23 $1,155.65 B. IMPROVEMENT COST: ADT TRIP RATE x NUMBER OF UNITS 9.57 1 ITEM 3 TOTAL - TRANSPORTATION SDC xl.;., COST: PEE..,TI~)P , $76.01 = , $892.31 x NEW TRIP FACTOR 1.00 x INEW TRIP FACTOR I 1.00 6000 $723.41 $656.56 $499.09 $164.89 $727.42 if.J W ~ o u ~ W IE-< if.J ...... o ~I r 1070 1091 1092 1093 1094 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: INUMBER OF FEU's x COST PER FEU 1 1 $314.63 B. IMPROVEMENT COST: NUMBER OF FEU's x COST PER FEU 1 $214.23 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL - MWMC SANITARY SEWER sm = , = , $394.76 - -~, --., SUBTOTAL (ADD ITEMS 1,2,3, & 4) 5. ADMINISTRATIVE FEE: 1 SUBTOTAL x I ADM. FEE RATE I $3,166.13 , 5% TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: $3,166.13 ....-- .. - - , CHARGE $158.31 4/13/2004 Virginia Jurasevich PREPARED BY = $314.63 1054 =, $214.23 j 1055 , ($144.10) 11054 I $10.00 11056 107,34 $50.97 DATE TOTAL SDC CHARGES = ,I $3,324A4 1079 1078 - - - - - -____L *EDU (Equivalent Dwelling Unit) is a discharge equivalent to a single family dwelling unit (20 DFU's) set at 167 gallons per day MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 CREDIT RA TE/$I,OOO ASSESSED VALUE $5.04 $5.04 . $4.95 $4.88 $4.75 $4.58 $4.41 $4,20 $3,88 $3.50 $3.07 $2.60 $2.14 $\.71 $\.52 $\.38 $1.19 $ \.03 ,$0.87 $0,68 $0.46 $0.27 $0,09 $0.04 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 11000 CREDIT RATE $29.11 x $4.95 = , CREDIT FOR IMPROVEMENT (IF AFTER ANNEXA nON) VALUE / 1000 CREDIT RATE " $0.00 x $4.95 , TOTAL MWMC CREDIT = o 1980 $144.10 o $144.10 l()(b k-S.M W 225 FIFTH STREET. SPRINGFIELD, OR 97477 0 PH:(541)726.37S3 · FAX: (541)72').3689 ELECTRJCAL PE~1IT APPLICATION City Joo Number ~~..lY\."ioq Date ":;' '~-, ~"'.C4.' ,'~:~; '~-;":~~~\"'~3!!': -':1'."'" ,:'''~':V~''_ ":' ~,';~'~,:, ::.- ~~H"W'," "",~""r'l:'...;'r~" 1., 'I..OC.AI10N u:FiNSTALIJ\TION-",'::~;4,:t '~~l: ".';'10 r " ~''i_"~',,,~:''''';l'-:~'''':;~,,:'''.' ~" ":<<1< '.' ~ :>"<""~,,::i:i>::\k'j.:/",; , :i:'Af<{.:'l'ft., : . ,';~: ;~J<':I __t\L\ f)~~~--t .;,"~ ":~~',;;,,, .."'"."L,;.;;, ,(: ';>~';' " \- ;1"':': .~:"; ".:". ",,~:f ,.' ",,~ .,.... ':"'t~:.. ,i ",/, ;..'1' ,-'l,:~.t\"",;,..... ;' ~'_" j<~' i J '. ", ' 3. ;'COM1'L,t:, J ~'FEES'CHEDl)[E lJEL914r.,,:~:t ~~~-1:~';:::,.": :,;,:\~:.~ ,.';',.... ' "\"':"~,"" '. .:...~".t;-').'!'. ,'1;,.,':'~.tW.t';: _.'. .,-''',''c, :;~:.:o:<,.,'<~ ".. ..c~:' ";"':-.';,..' ." .;,~;,.., l'L'~; ..>".'.:c., "',", .~:.. 4":;;"";,~..J5<",..". .;'v,'''''''\>'t..'_~..l''~~ ....J: <? :.." 'r;,::'~'~ ':"":-'::";_ ~.: :, ~...-, --'~".'~,~,~:>.~:,~'; ~~j:' ~';;:'" '('" ,,"- '" t,,,~.,;',. '.-:. , "" ~ ;~',.,. ..... .,' \..:~; A. ,N e,~:lt~j(j,~~tiaI7f Sing! e;(lrM' .Iti. Fllp;ll,lY 'p'e~d~~~~ingjinit., .. ......~ r/',.'l.,m-..,."';_".""" ",~"",_"",.-.~..,.. ,':'1..,,< '..,' ..,.'. ,.....'.,....'-1.;,.. "."'.',,.......,..'-"..,., .......~.....~~.., Service Included LEGAL DESCRIPTION _tJD'L~~,. OC)G\()() JOB DESCRIPTION*' - ~OO ~n~~:'\.~x:'~w~~ not started wit~~~~ days of issuance or if work is Suspended for 180 days. lDto(JO \~ \ 4 $106.00 1000 sq. ft. or less Each additional 500 sq. ft.)T portion thereof Each Manufact'd Home or Modular Dwelling Service or Feeder $ 19.00 $50.00 B. ;1::$rJ~i'~~~~f:F~~d;r~~) .i~~i~iij';~;iAf~1i~~~~1'19i~;;~:~jj~;~ri~~ ,h" :'-l,",l';;~~:;,:'; .:.~: '~'.:t.o.,{\"9f.;\..iJ.,.;J;:iI;.s.:'j" ~ ,7:J'_'~:..r::.n.:ti.;~;.;;'\;"\i:: .,,':; We 1~:.{;;"';~'1-.~,JJ~"""-~.L~-<.t",~;.;~,,Jil~~. 'W'.*".t~ .~ :~..: 2. ~~~l2\~' ,,~~~~i!~~t11~:~~YrrB~,~g~~~~,f , Electrical Contractor Lyu-JJ.:S f5ltc:tR.,f...:. Address .:r~.::....M- A City f'A\\ c.~~_ Phone -r~Au -1elf) $ 63.00 $ 75.00 $125.00 $163.00 $375.00 $ 50.00 200 Alnps or less 201 Amps to 400 Amps 401 Amps to 600 Amps 601 Amps to 1000 Amps Over 1000 AmpsIVolts Reconnect Only c. :~'T1J[:f~f~~~~rii~~~'~~rFkT~ZWf~ . ':-c.~:,~.:;{~,.1)~,,:~ '~~;":~~~;_'-"'W(~,;i.:.~:~ .',;.!~;Ui,;,"r'"':" ;~: '<{~ '~ ~ 351-5 IO/()/!OV I 200 Amps or less Consa. COlltI'. Number J 0 ~ :5 I '" 201 Amps to 400 Amps Expir<ltioD Date /0 Jo,l Of NOTICE: 401 Amps t~~~~ \w:\OIl .. , I I THIS PERMIT S~.~\rtgtX,~!'~ or DUI\lI.Y ~l~e B above. SignatL:re of Supervising Electrician AU1HOR\ZEDIUNtm.Wll!t~1@ '<. '"- j) IA I COMMENCED OO~M~~rP r x enslOn Per Pallel ___~~ .. I'VL~~180DAY~1~b6it __ Each Additional Circuit or with Service or Feeder Permit SUperv1'iOr License Number Installation, Alteration or Relocatio 1 \ Ex.prration Date nO .of) $ 50.00 $ 69,00 $100.00 $ 43.00 $ 3.00 \ C-r'{~ \'~ ~ . Address ~ D ~{0 ~ City ~_ \\\\ \- Phone .:;,.:~t ':':,--:,?:,'~~,r;~""~'\;\rT \tit::;li"t.,.~.,-~,.,~", i'1",-:,,::, l'<~~<~+, ,.r;~'",:,~:" ~')~~:~~",:"':-'''''/.''14, J." ..-:"',~ ", _,,:;,.-'1:'":'~:''':;':'' E.: lVlisc~llane:oitS. (Se'rvi~~/fe~der ~~nllcludedi~Ea~K InstAi.l~do{~ '\>~ :-,~'~:~;7d;':~;:l:."';' .: '-::,,:{;,:: ~,~1-t~~~:y " , ',~~.;~ '':'~!'''''':'~ /.."/~' :'~ ~. ;~~~~1;~1t...:-..~~~,'::"!'i""'-h.-:~i<:',I. ~.j"'::'"',.t<,,~ .'. ;~."':S.;j?:. ~~~to Notifidallon Center. byi~~ $ 50.00 OW~ER INSTALLATION In OAR 952"()01.oo1~r:a __to_tial ._ $ 25.00 '['h' 1" '.. ad noocq v...... -J:luobtaIn...l..iJ dJ:M8.~~rcial $ 45.00 ,e lUsta .atlCn 1S oemg m e on prop"e. 68 .?~!1I-e81 IUUp Ot'tfti 8 - is not intended for sale, lease or rent. IIlOg the C8"*,,~~Jpfnspection Fe. is $45.00 + Surcharges number for the O~Ott.~ . 'mml.~'. '''.'.'' .....""..'''''.;,..'.;.'....'''...''.'...'. '.;"'.';;'" t1"'-.'L ~ Center Is 1~4a44~~:-:~,~~;;b~i];,~i;,:;f::?;h\ 'J-v .UJ 7% State sur:h~~~'~ .'" '...'" . \ \o.~ 10% Administrative Fee ~ .1D ~1l t\4 $ 50.00 Owners Signature: TOTAL inspection Request: 726.3769 Shared Drive(T:)lBuilding FonnsiElectnclll Permit Application I-03,doc