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Permit CITY OF TIGARD MASTER PERMIT 11111 ' COMMUNITY DEVELOPMENT Permit#: MST2021-00309 Date Issued: 09/28/2021 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S106DA18000 Jurisdiction: Tigard Site address: 16672 SW BIRDSONG ST Subdivision: RIVER TERRACE EAST 2 Lot: 219 Project: Coleman Project Description: Install a new 420 sqft deck. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 12 Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Total: 0 sf Value: $10,768.80 Rear: 5 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 0 Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Bckflw Prevntr: 0 Drywell-Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Fum<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp. 0 0-200 amp: 0 W/Svc or Fdr: 0 Ea add'I 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0 Mfd Home/Feeder/Svc. 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+amp/volt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All N Other: N Other Description: Ecompasing: BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ALT SF VB R-3 0 Owner: Contractor: COLEMAN,SCOTT C&KATHERINE M DICK'S EVERGREEN FENCE&DECK Required Items and Reports(Conditions) 16672 SW BIRDSONG ST 4815 SE TV HWY TIGARD,OR 97007 HILLSBORO,OR 97123 PHONE: PHONE: 503-640-7700 FAX: 503-640-0466 Total Fees: $743.64 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR OF7_nni_nnln ehrniinh nAt7 arc-nnl-nnon Vn,i mat/nhtain a nnnv of tha ndaa nr errant nilacfinne In nl Il\I/"ht/naiiinn Fri'737 1057 nr 1 AM Ti7 7(44 Issued By: DI:WC.ge- Permittee Signature: Ow Ar�r Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Buildin Pg ermit Apn. c tion -7 I' Residential 1 'k n;.., ,r' 1, . ' FOR OFFICE USE ONLY F City of Tigard JUL 10 2021 Dateive o't" 20 I =.! Permit No.MST 202/-Z 30? ' 13125 SW Hall Blvd.,Tigard,OR 97223 pin R�;� Q ' 2 Phone: 503.718.2439 Fax: 503.598.19 Date/B v 1jI Other Permit: �i I�Y OF TfGHH� y� Inspection Line: 503.639.4175 Date Ready/By: Saris: Fd See Page 2 for TiC^A./ Internet: www.tigard-or.gov BUILDING G DIVISION IO 7d�leth«I: IC ��� Supplemental Information [-r—i TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING New construction ❑Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all fiAdditionialteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit(pig the CATEGORY OF CONSTRUCTION work indicated on this application. (tj I -7(p'D,t0 Valuation: $—'t(j "'Dt 7-and 2-family dwelling ElCommercial/industrial ElAccessory building 0 Multi-family Number of bedrooms: ❑Master builder 0 Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: +6,7 2_ 5 u a i rottort St New dwelling area: square feet 17 City/State/ZIP: 3 eave s•tort/(2 iZ `i`7 00 7 Garage/carport area: square feet Suite/bldg./apt.no.: Project name: Co,et.,,a" Oe*e,k Covered porch area: square feet /1, Cross street/directions to job site: 5(„) Rive r Ter,-,,ce (3 ►✓& Deck area: l square feet Other structure area: square feet REQUIRED DATA:COMMERCIAL-USE CHECKLIST Subdivision: Lot no.: Permit fees*are based on the value of the work performed. indicate the value(rounded to the nearest dollar)of all Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. .)..^c I oj't 'e" Feet. J+#-ei.fi r j 0 e Gk. ✓ r f 1, Valuation: $ S 1- -S on slr S of A/c ca 0`. E ;r'fie A.1.s Existing building area: square feet New building area: square feet X PROPERTY OWNER ❑ TENANT Number of stories: iName: se, it .1- rL.Q+%e (a(e Art Type of construction: Address: (C[7 2. sr--, a l,-,(f on) S+ Occupancy groups: — City/State/ZIP: 3et.ve r dot-. tr_Ot'( 'I`200-7 Existing: Phone:(fig) 30.7 - ?16 Y Fax:( ) New: APPLICANT 1 CONTACT PERSON BUILDING PERMIT FEES* Business name: p t c Is S eve y re c r e n e e 0 (Please refer to fee schedule) F .e� �e G�( Structural plan review fee(or deposit): 3S •2I Contact name: e ht r,f go le FLS plan review fee(if applicable): Address: if r t 5- se- v H .., t/ City/State/ZIP: Hilt,bo.•0 OR ' 7 1 7-3 Total fees due upon application: Amount received: Phone:(5 b 3) 313..E J zz Fax::(S-b 3) 6'O- O q6.6) k PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* E-mail: Aic, f CVC�0�eEn K7Ai ( . GOa+"-- Commercia►and residential prescriptive installation of CONTRACTOR roof-top mounted PhotoVoltaie Solar Panel System. Business name: biG{t f e✓t rg et eM Fen GC Qe o Submit two(2)sets of roof plan with connection details _ and fire department access,along with the 2010 Oregon Address: i/)7 C I S— f T V 14 w y Solar Installation Specialty Code checklist. City/State/ZIP: f f/7/t I o 0A q 7(..3 Permit Fee(includes plan review $180.00 i and administrative fees): (, Phone:( 93) '/O— -71 vo Fax:( SI)) 6q0 —p 5(4 6 State surcharge(12%of permit fee): $21.60 CCB lie.: /0 8?$-t7 Total fee due upon application: $201.60 Authorized signature: dio �' This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: ih rls iv'A ty, A, aa v/e Date: 7/I z/2 "Fee methodology set by Tri-County Building Industry J Service Board. I:\BuildingTcrmits\BL-P-RESPcrmitApp.doe 02/24/2011 440-4613T(1 I/02/COM/WEB) City of Tigard I COMMUNITY DEVELOPMENT DEPARTMENT illIl . C TIGARU' Building Permit Review — Residential A Building Permit #: 1,4Sr2O2-I-0O30F Site Address: /6412 cc.') 1f e_pca NG rTi Project Name: C,o L WA hi DEt-!L Lot #: 2. 161 Planning Review Pro al: NI e C GlC_._. rid Verify address/suite #active in Accela. I. In River Terrace: ❑ No es,River Terrace Review Addendum Sit lan Elements: []Erosion Control e'opies of site plan on 8-1/2"x 11"or 11 x 17"paper [i]Retained trees with drip line and tree protection measures D .wn to scale(standard architect or engineer scale) Footprint of new structure(including decks) and FFE I. .rth arrow U..: locations&easements(required for new and additions) 4e address,project or subdivision name and lot number / idewalk/driveway approach Y�JAlicant information (name and phone number) u J1Location of wells/septic systems [ tot dimensions and building setback dimensions `- II S et tree size,type and location PEI Saxe footage of buildings to be demolished treet names E txisting structures on site L 1Corner elevations(2'contours if more than 4'differenti ) 4ILot area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? ❑Yes No kitr iimm ervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? EYes No l� Clean Water Se i es—Service Provider Letter (lot platted prior to 9/10/1995): uired: lQ Yes,applicant was notified ❑ No Received: ❑ Yes ❑ No Water Meter Fixture Unit Worksheet—Additions,Remodels and ADUs Duired: ❑ Yes,applicant was notified Er—No Received: ❑ Yes E No C Exemption for ADU applied for: ❑ Yes 12r5o Received: E Yes ❑ No 1? Public Facilities Improvement (PFI)Permit: ��Required: ❑ Yes,applicant was notified L� No ^� Applied For: ❑ Yes ❑ No,stop intake [ Land Use Case#: >2.01G — d -1, ❑ Zoning: (Z`3' ❑ Re.uired Setbacks: Front: 12- Rear: Side: Street Side: NA Garage: Z ❑ :uilding Height: -- Max. Height: .35 Actual Height: ill nn Landscape Area: 2l7 % Or Lot Coverage Max: • ' • ❑ Set back no more than 8'from street-facing wall ❑ Par. . reet or offset 45 degrees or less Windows ■ :.. 12%of area of all street-facing facades Garage ❑ Garage door i .-.. d widest street-facin_ , .. ❑ Yes ❑ No,one of the following is met: ON ❑ Door extends no mo _.,• .' rom wall and there is a covered porch extending beyond garage. ❑ Door extends n. .re than 5' ro .11 and there is a 12 sq ft.window above garage on 2nd floor. ❑ Garage doo i is ❑ 12'or less ❑ 50%o _ of facade ❑ 60%or less and includes 7 of following: ■ -overed porch ❑ Recessed entrance ❑ Wall o ❑ 1'Roof eave ❑ Roof offset ❑ Fire shingles ❑ Lap Siding ❑ Roof pitch ❑ Gab e, :• or gambrel roof ❑ Dormer ❑ Accent siding Window trim ❑ Window recess ❑ Win.o, . ojection ElBalcony !Visual Clearance Urban Forestry Plan , v itive Lands: CI Yes ��o Type: Conditions met prior to issuance of building permit Not Approved By Planning: Date: g 3 2I Revisions (after Building Submittal on y) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved I:\Building\Forms\BldgPermitRvw_RES_122419.docx ,,, Building Permit Submittal Original Submittal Date: 07/I t/2-O2j Site Plans: # Building Plans: # aj Building Permit#: [Enter building permit# above. Workflow Routing: ©'Planning ®- Engineering a--Permit Coordinator (`Building Workflow Sign-off: L'Sign-off for Planning(include notes from planning review) Route Application Documents: ['Engineering: (1) copy of permit application, (1) site plan, (1)building plan and original plan review routing form. Er-Building: original permit application, site plans,building plans,engineer and beam calculations and details,if applicable,etc. Notes: By Permit Technician: Date: e eoc/ 24 Engineering Review ❑ Slope at building pad: LP/Conditions "Met"prior to issuance of building permit C /Easements (encroachments)per engineering conditions of approval and plat Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes /No Assess Water Quantity Fee in-lieu: ❑ Yes ( No LIDA Facility on lot: ❑ Yes �'No ❑ Final Plat Recorded: ❑ NOT Approved by Engineering: Date: Notes: proved by Engineering: �-� Date: 2./ Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Permit Coordinator Review ( Conditions "Met"prior to issuance of building permit ❑ Approved,NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: Revision Notice 2: Date Sent to Applicant: ,?''SDC Exemption: ❑ Received Does not apply • SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes gi N/A Tigard Trans SDC: ❑ Yes Z N/A Parks SDC: ❑ Yes N/A LIDA ❑ Yes N/A 12'OK to Issue Permit Approved by Permit Coordinator: Date: 8(5.12024 I:\Building\Fonns\B1dgPermitRvw_RES_122419.docx City of Tigard N COMMUNITY DEVELOPMENT DEPARTMENT T1cARD Building Permit Review — Residential f.fBuilding Permit #: PAS'2021_ 01)3 ASite Address: NM 2 jtl(dctmg Project Name: CO(ern Lot #: Planning Review • Proposal: I nbta 11 llj4 c eGK 'a (30I 21 ReviSel> PLANC 7b 0E14 OVA SrAi es ❑ Verify address/suite#active in Accela. ❑ In River Terrace: ❑ No ❑ Yes,River Terrace Review Addendum Site Plan Elements: ❑Erosion Control 03 copies of site plan on 8-1/2"x 11"or 11 x 17"paper ❑Retained trees with drip line and tree protection measures ❑Drawn to scale(standard architect or engineer scale) ❑Footprint of new structure(including decks)and FFE fEl North arrow ❑Utility locations&easements (required for new and additions) ❑Site address,project or subdivision name and lot number ❑Sidewalk/driveway approach ❑Applicant information(name and phone number) ❑Location of wells/septic systems ELot dimensions and building setback dimensions ❑Street tree size,type and location ❑Square footage of buildings to be demolished ❑Street names ❑Existing structures on site ❑Corner elevations(2'contours if more than 4'differential) ❑Lot area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? EYes ❑No impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? :Wes ❑No ❑ Clean Water Services—Service Provider Letter (lot platted prior to 9/10/1995): Required: ❑ Yes,applicant was notified ❑ No Received: ❑ Yes ❑ No ❑ Water Meter Fixture Unit Worksheet—Additions,Remodels and ADUs Required: ❑ Yes,applicant was notified ❑ No Received: ❑ Yes ❑ No ❑ SDC Exemption for ADU applied for: ❑ Yes ❑ No Received: ❑ Yes ❑ No ❑ Public Facilities Improvement(PFI)Permit: Required: ❑ Yes,applicant was notified ❑ No Applied For: ❑ Yes ❑ No,stop intake ❑ Land Use Case#: ❑ Zoning: ❑ Required Setbacks: Front: Rear: Side: Street Side: Garage: ❑ Building Height: Max. Height: Actual Height: ❑ Landscape Area: % ❑ Lot Coverage Max: cyo Entrance ❑ Set back no more than 8'from street-facing wall ❑ Parallel to street or offset 45 degrees or less Windows ❑ Minimum 12%of area of all street-facing facades Garage ❑ Garage door is behind widest street-facing wall ❑ Yes ❑ No,one of the following is met: ❑ Door extends no more than 5'from wall and there is a covered porch extending beyond garage. ❑ Door extends no more than 5'from wall and there is a 12 sq ft.window above garage on 2nd floor. ❑ Garage door width is ❑ 12'or less ❑ 50%or less of facade ❑ 60%or less and includes 7 of following: ❑ Covered porch ❑ Recessed entrance ❑ Wall offset ❑ 1'Roof eave ❑ Roof offset ❑ Fire shingles ❑ Lap Siding ❑ Roof pitch ❑ Gable,hip,or gambrel roof ❑ Dormer ❑ Accent siding ❑ Window trim ❑ Window recess ❑ Window projection ❑ Balcony ❑ Visual Clearance ❑ Urban Forestry Plan ❑ Sensitive Lands: ❑ Yes ❑ No Type: ❑ Conditions met prior to issuance of building permit Notes: ❑ Approved By Pl ning: Date: Revisions (after B ding Submittal only) Reviewer D tc Revision 1: Approved ❑ Not Approved /i/1J Revision 2: ❑ Approved ❑ Not Approved , I I:\Building\Forms\BldgPermitRvw_RES_122419.docx Building Permit Submittal Original Submittal Date: Site Plans: Building Plans: # Building Permit#: ❑ Enter building p rmit#a ove Workflow Routing: ❑ Planning ❑ ngi,e-- ng ❑ Permit Coordinator ❑ Building Workflow Sign-off: ❑ Sign-off fo la ti lude notes from planning review) Route Application Documents: ❑ Engineering copy of ermit application, (1) site plan, (1)building plan and original pl. • review routing form.. . ❑ Buil•'•t: original permit application, site plans,building plans, engineer and • b-:m calculations and trust details,if applicable,etc. Notes: By Permit Technician: ,.% Date: Engineering Review ❑ Slope at building pad: ❑ Conditions "Met"prior to issuance of building permit ❑ Easements (encroachments) per engineering conditions of approval and plat ❑ Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes ❑ No Assess Water Quantity Fee in-lieu: ❑ Yes ❑ No LIDA Facility on lot: ❑ Yes ❑ No ❑ Final Plat Recorded: ❑ NOT Approved by Engineering: Date: Notes: ❑ Approved by Engineering: Date: Revisions (after B lding Submittal only) wer Date Revision 1: Approved ❑ Not Approved 9/7/2 Revision 2: ❑ Approved ❑ Not Approved Permit Coordinator Review ❑ Conditions "Met"prior to issuance of building permit ❑ Approved,NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: h(1... cl( I bi 2.0 Revision Notice 2: Date Sent to Applicant: SDC Exemption: ❑ Received Does not apply SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes (ErN/A Tigard Trans SDC: ❑ Yes te N/A Parks SDC: ❑ Yes k N/A LIDA ❑ Yes ,] N/A OK to Issue Permit Approved by Permit Coordinator: Date: 0) ( i/5 t o' 1:\Building\Forms\B1dgPermitRvw_RES_122419.docx City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT i TIGARD River Terrace Building Permit Review Addendum Building Permit #: M 57202_( -00 30? Site Address: I(& 12 StAJ 13112.0Sc,4UL-' Sr Project Name: C-x, p.N (Dsit, Lot #: 2.16\ (New dwelling=subdivision name;Addition or Alteration=last name of owner) Planning Review of River Terrace Plan District Design Standards (18.640.070.1): Is the project subject to the plan district design standards? ❑ Yes ❑ No .Articulation: a minimum of 1 element per each street-facing facade that has 30-60 ft.of frontage.An .-:'tional e • ent required for lots with over 60 ft. of street frontage shall be provided every 30 ft. Balcony w/access 2 Window Projection Vertical Wall Offset a Porch 5 ft.deep ft.deep min.2ft., 5 ft.wide min.2 ft.,6ft.wide abled dormer ❑ ❑ ❑ ❑ ❑ 2.Eyes on the stree a minimum of 12%of each street facing facade must include : dows or entrance doors. Percentage Shown: 3.Entrances:At least one entra e must meet both of the following standa .s: ❑ Max. 8 ft. setback from longest stre.. -facing wall ❑ Parallel t• street,angle no more than 45° from street, or open • to porch Entrance opens to a porch: ❑ Yes ❑ No If yes,all the following apply: ❑ sq.ft.min. ❑ One street facing entry I. 12 ft.max. roof above floor of porch El 5 ft.depth min. El 30%min.porch roof coverage 4.Detailed Design:All buildings shall include a min. . five • the following elements on all street-facing facades: El Covered porch min. 5 ft.wide x 5 ft. deep ❑ ' . essed entry area min. 5 ft.wide x 2 ft. deep ❑ Wall offset min. 16 inches ❑ Do -r min.4 ft.wide ❑ Roof eave min. 12 inch projection ❑ Roof of -t min. of 2 ft. ❑ Roof shingles either tile or wood ❑ Gable,hip o •ambrel roof design ❑ Roof pitch oriented south min. 500 s•. ft. ❑ Horizontal lap '.'ng min. 3-7 inches wide ❑ Accent siding min.40%of street f ade ❑ Window trim min. ' '/2"wide by 5/8"deep ❑ Window recess min.3 inches f• all street facing El Bay window min. 5 ft. .ide by 2 ft. deep ❑ Balcony min. 5 ft.wide x 3 f.deep with inside access ❑ Attached garage is 35%o ess of street facade 5. Garages and Carports ay face the front or side lot line on a corner lot. Setbacks: No closer to front o side lot line,than longest street-facing wall. ❑ Yes ❑ No. If No (Check one): ❑ May extend u• to 5 ft.if there is a covered front porch and garage does not extend beyond the front orch. ❑ May exten' up to 5 ft.where the garage is part of a two-story building and there is a window at the seco.d story above the ...rage that faces the street with a min. area of 12 sq.ft. Width- Check one) ❑ -foot-wide garage door ❑ 40%max. of street facade li 50%max. of street facade with 7 detailed desi. elements Notes: . Approved By Planning: Date: I:\Building\Forms\Bl dgPcimitRvw_RES_RT_1214 I 7.docx FOR OFFICE USE ONLY-SITE ADDRESS: This form is recognized by most building departments in the Tri-County area for transmitting information. Please complete this form when submitting information for plan review responses and revisions. This form and the information it provides helps the review process and response to your project. 1 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT _ . Transmittal to Letter T I(:,A Ez r) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov TO: Ni k k; !rn(,.Sor- DATE RECEIVED: DEPT: BUILDING DIVISION RECEIVED FROM: (l+rise &o y fe /� AU COMPANY: DTck.s ev/cr�Jgi f h f , A 0Eck , t, 3 0 ITY OF TIG20 RU PHONE: (9-3) 3I 3— S 7 Zc- lUILDING DIMIIS10N— EMAIL: Ai c k s c✓e rre c Z ^ vt.j I, co w RE: /667Z si) 6,r S o�o,•,' St- , F�eo.ver�v� M T- 2O Z t - o 3 O q (Site Address) (Permit Number) Co(eh' ., De GL (Project name or subdivision name and lot number) ATTACHED ARE THE FOLLOWING ITEMS: Copies: Description: Copies: Description: Additional set(s)of plans. 3 Revisions: Eli ; + j 54.4 41' Cross section(s)and details. Wall bracing and/or lateral analysis. Floor/roof framing. Basement and retaining walls. Beam calculations. p Engineer's calculations. )c Other(explain): a v,f�l f;+,, el gki&_ REMARKS: put 1-o se +LA 61...,t-.1710 v we- a,e, a 6,..4,1, s-)ia--J Iv et"- feoe-t e/ erve,-- , 8t-h- ee, He # t'x,iJ Dee,ks. { FORTFFI�jE USE ONLY Routed to Permit Technici Date: l (./21 Initials: Fees Due: ❑ Yes NK Fee Descripn: l Amount Due: $ N.,r i 1 tr.: .. .'....----- $(‘--/ $ Special Instructions: Reprint Permit 6' p (per PE): ❑ Yes No ❑Done Applicant Notified y� Date: �y7,�,j/z ( Initials: '