2006, 04-25 Permit App: 06001274 Residence Project Number: 06001274 Inv: 1 Application Date: 4/25/2006 Page 1 of 3
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Project Information:
Permit Use: SINGLE FAMILY DWELLING,GAS HEAT ON Contact: HASLEY,MICHAEL&GAIL
SEPTIC Address: 1115 S PARK RI)
C-S-Z: SPOKANE VALLEY,WA 99212
Setbacks:Front Left: Right: Rear: Phone: (509)000-0000
Group Name:
Site Information: Project Name:
Plat Key: Name: Range District: Sout
Parcel Number: 35244.1805 Block: Lot:
SiteAddress: 6703 E 14TH AVE Owner:Name: HASLEY,MICHAEL&GAIL
Address: 1115 S PARK RD
Location::CSV SPOKANE VALLEY,WA 99212
Zoning: UR-3.5 Urban Residential 3.5
Water District: Hold: ❑
Area: .00 Acres Width: 0 Depth: 0 Right Of Way(ft): 0
Nbr of Bldgs: 0 Nbr of Dwellings: 0
Review Information:
Review
Building Plan Reviewda , . �
Originally Released: 4/12/2006 By: amblake
Driveway/Approach
OdBy 9 a
...--- ,
Originally Released: 4/12/2006 By: amblake
rre
Septic Sys Review aft'l'"�:,n ���� = ,
E�lease ��M����� x„
.fli- TJ
see file
Originally Released: 4/25/2006 By: amblake
Landuse/Zoning/HE Conditions Released By: 11 -7,7 7'
Originally Released: 4/12/2006 By: CJJANSSE
Operator: AMB Printed By: AMB Print Date: 4/25/2006
Project Number: 06001274 Inv: 1 Application Date: 4/10/2006 Page 1 of 2
THIS is NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Project Information:
Permit Use: SINGLE FAMILY DWELLING,GAS HEAT ON Contact: HASLEY,MICHAEL&GAIL
SEPTIC Address: 1115 S PARK RD
C-S-Z: SPOKANE VALLEY,WA 99212
Setbacks:Front Left: Right: Rear: Phone: (509)000-0000
Group Name:
Site Information: Project Name:
Plat Key: Name: Range District: Sout
Parcel Number: 35244.1805 Block: Lot:
SiteAddress: 6703 E 14TH AVE Owner:Name: HASLEY,MICHAEL&GAIL
Address: 1115 S PARK RD
Location::CSV SPOKANE VALLEY,WA 99212
Zoning: UR-3.5 Urban Residential 3.5
Water District: Hold: ❑
Area: .00 Acres Width: 0 Depth: 0 Right Of Way(ft): 0
Nbr of Bldgs: 0 Nbr of Dwellings: 0
Review Information:
�.��i�m�„ ,ax�,i ����uza.<� a�^rv�awauh�wwra�rix�,zatsw.,Fa�aaw.^�z�ea�eM<<w�. r4: .. . i I&!da,i ,_mgra,abuaswuAm.„e,rv�r. wa�r
Review
Building Plan ReviewRele ed yr�
gar Citi
Driveway/Approach Released
Septic Sys Review P Y Released By
.
Landuse/Zoning/HE Conditions Released Sy . , ,�,x ,. 11 ,
Approach
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Operator: AMB Printed By: AMB Print Date: 4/10/2006
APE 25 2006 10 50 FR TO 3241567 P.01/03
Project Num x r: 06001274 Inv: 1 Application Date: 4/10/2006 Page 1 of 2
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
project if r_,•oration: .
Permit Use: SINGLE FAMILY DWELLING,GAS HEAT ON Contact: HASLEY,MICHAEL&GAIL
SEPTIC Address: 1115 S PARK RD
C-S-Z: SPOKANE VALLEY,WA 99212
Setback;::'t ont Left: Right: Rear: Phone: (509)000-0000
Group Name:
Project Name:
Site Inforrn,c!tion:
Plat Ke r Name: Range District: Sout
_
Pate Number: 35244.1805 Block: Lot:
ii cAddress: 6703 E 14TH AVE Owner:Name: HASLEY,MICHAEL&GAIL
Address: 1115 S PARK RD
Location::CSV SPOKANE VALLEY,WA 99212
Zoning: UR-3,5 Urban Residential 3.5
Water District: Hold: ❑
Arca: .00 Acres Width: 0 Depth: 0 Right Of Way(ft): 0
Nbr of Bldgs: 0 Nbr of Dwellings: 0
Review lid rimation: ,,.
Revinv
Built li ig Plan Review r .1,` ' `,�h t ..... ......... _.,—,;.'4011aN.�.+''�
Dr iv:t ray/Approach r Zi
- ..-. ... , _-- ... ... ..
Se 3t.c Sys Review -1: ;, .,...:z`s .k �x :,,
drOoma,or_-4LaU gallons par day. 6;Ot .' f
__
1 ilriallailoot kr$RHO approval.
Lan u se/Zoning/HE Conditions 'Nu�M e.._.....— ". .,.-....,
Permits: .. -- ._ _ vrrr.uurrr
Approach - —
Contrac:or: OWNER Firm: •OWNER
Phone: (000)000-0000
Ope 210 1 AMB Printed By: AMB Print Date: 4/10/2006
Project Number: 06001274 Inv: 1 Application Date: 4/10/2006 Page 2 of 2
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Building Permit
Contractor: OWNER Finn: OWNER
Phone: (000)000-0000
Mechanical Permit
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Plumbing Permit
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Notes: .,. .
CONTOL AREA FOR DRAINAGE MORITORIUM SEE MAPS FOR SPECIFICS
Payment Summary: a., p�ro,w��a a eta - mmira xaig� w „ :. io ivr, r. 4 .aq z
Disclaimer:
Submittal of this application certifies the owner(or person(s)authorized by the owner)has both examined and finds the information
contained within to be true and correct,and agrees that all provisions of laws and/or regulations governing this type of work will be
complied with. Subsequent issuance of a permit shall not be construed to be a permit for,or an approval of,any violation of any of
the provisions of the code or of any other state or local laws or ordinances.
Signature:
Operator: AMB Printed By: AMB Print Date: 4/10/2006
Project Number: 06001274 Inv: 1 Application Date: 4/25/2006 Page 2 of 3
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Permits: w � u gas wq waea_x, tea.e ,o i .r w.., r .,ern ..,,eas Rrwwa ,.
Approach
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Item Description Units Unit Desc Fee Amount
APPROACH-CONST IN ROW 1 NUMBER OF $50.00
Permit Total Fees: $50.00
Building Permit
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
This Application: Total Project:
Description Grp Type Notes Sq Ft Valuation Sq Ft Valuation
1&2 FAMILY R-3 VB 1,863 $160,907.31 1,863 $160,907.31
BASEMENT U R-3 VB 400 $6,000.00 400 $6,000.00
DECK OPEN R-3 VB 105 $1,575.00 105 $1,575.00
GAR WOOD U-1 VB 704 $13,376.00 704 $13,376.00
Totals: 3,072 $181,858.31 3,072 $181,858.31
Item Description Units Unit Desc Fee Amount
RESIDENTIAL PERMIT FEE 1 SELECT $1,452.95
WSBC SURCHARGE 1 SELECT $4.50
SF PLNS RVW<7999 SQ FT 1 SELECT $581.18
Permit Total Fees: $2,038.63
Mechanical Permit
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Item Description Units Unit Desc Fee Amount
GAS WATER HEATER 1 NUMBER OF $10.00
GAS PIPING 2 #OF UNITS $2.00
CLOTHES DRYER 1 NUMBER OF $10.00
RANGE 1 NUMBER OF $10.00
Permit Total Fees: $32.00
Operator: AMB Printed By: AMB Print Date: 4/25/2006
Project Number: 06001274 Inv: 1 Application Date: 4/25/2006 Page 3 of 3
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Plumbing Permit
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Item Description Units Unit Desc Fee Amount
TOILETSBIDETS 2 NUMBER OF $12.00
SINKS 4 NUMBER OF $24.00
SHOWERS 1 NUMBER OF $6.00
TUBS 2 NUMBER OF $12.00
DISH WASHERS 1 NUMBER OF $6.00
GARBAGE DISPOSAL 1 NUMBER OF $6.00
CLOTHES WASHER 1 NUMBER OF $6.00
Permit Total Fees: $72.00
CONTOL AREA FOR DRAINAGE MORITORIUM SEE MAPS FOR SPECIFICS
Payment Summary: a ; s� i �„ ,,_.ar:�w; MENEBNIMENESI
Permit Type Fee Amount Invoice Amount Amount Paid Amount Owing
Approach $50.00 $50.00 $0.00 $50.00
Building Permit $2,038.63 $2,038.63 $0.00 $2,038.63
Mechanical Permit $32.00 $32.00 $0.00 $32.00
Plumbing Permit $72.00 $72.00 $0.00 $72.00
$2,192.63 $2,192.63 $0.00 $2,192.63
Disclaimer:
Submittal of this application certifies the owner(or person(s)authorized by the owner)has both examined and finds the information
contained within to be true and correct,and agrees that all provisions of laws and/or regulations governing this type of work will be
complied with. Subsequent issuance of a permit shall not be construed to be a permit for,or an approval of,any violation of any of
the provisions of the code or of any other state or local laws or ordinances.
Signature:
Operator: AMB Printed By: AMB Print Date: 4/25/2006
NIG/Cane 11707 E Sprague Ave, Suite 106 PERMIT NUMBER D-N
400000 umValeJ (5Spo09kane)688-993 Valley,WAFAX: 99206(509)688-0037 PERMIT FEE:
-
Co ;iaity Developme �'s;��'
nt .spo r �e1�v.��.e.�z�; RI, (� r---\'',
'
[
Residential C ( APR 10
onstructi NTw.Construct>ion o Accessory Bldg
Permit Application .Au . .'on/Remodel o Deck
[UJ II 1_1_, I:),) I I cObt, et:
srrE ADDRESS eo "7 O 3 �.: /-4/77111-4,4,-- .S Pog#iV6= Vi4-f 1 in=v 40i_ g qL1Az
ASSESSORS PARCEL NO:-36.024-1 - /Par- LEGAL DESCRIPTION: ea()Fri/T A&7. I&.S" 6
Building owner ` a'• . . . : ., :. Contractor: , .;.,' : -
Name: M/ilZL� )44 ( y Name:
Address: /7`0, 11;/1 I A &i---(— . Address: .
City: ci2t)le -rug- Zip: 41 A) 3 City: Zip:
Phone: 9/ 7 c33/3 Fax: - Phone: Fax:
Lic No: Exp.Date:
iii tactPerson:. . . : .:;:t,_ �tt.•: :i,:t; {:
•
City Business Lic No:
Name: ,4 i 4- / L L
` Phone: r,'il7fie
Describe the scope of work in detail:
� Cost of Project: $ /,',2_,s;-Doo r'-
) k /A/ / Tc/ e--Nnet Ce vsrggtec j ioiy
**************The following MUST be complete: (write N/A if not applicable)**********************
HEIGHT TO TO PEAK: DIMENSIONS: #OF STORIES: HABITABLE SPACE:
c20 r ..5"ol ° x 41C G. 3
MAIN FLOOR TO SQ. 21V"FLOOR SQ. FTG: UNFIN BASEMENT SQ. FTG: IMPERVIOUS SURFACE
FTG: is '/a 3 .._-- 00 ` OIL AREA
FINISHED BASEMENT GARAGE S'% ,Q. FFIG / DECK/COV PATIO SQ. FTG: 30% SLOPES ON
SQ. FTG: L d /® _ PROPERTY:
#OF BEDROOMS: CONSTRUCTION TYPE: HEAT SOURCE: SEWER OR PT1 ? `i
DISCLAIMGZ ER F4/4ML7� c J4 s Fu f-i11/ C L-
The permitee verifies, acknowledges and agrees by their signature that 1) if this permit is for construction of or on a dwelling,the
dwelling is/will be served by potable water. 2) Ownership of this City of Spokane Valley Permit inure to the property owner. 3) The
signatory is the property owner or has permission to represent the property owner in this transaction. 4) All construction is to be done
in full compliance with the City of Spokane Valley Development Code. Referenced codes are available for review at the City of
Spokane Valley Permit Center. 5) This City of Spokane Valley Permit is not a permit or a...4pproval for any violation of federal,state or
local laws,codes or ordinances.6) Plans or additional information may be required to be submitted,and subsequently approved before
this application can be processed.
Signature ,L i Date ' 6 C &
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
0 Cash 0 Check 0 Mastercard 0 VISA 0 Other
Bankcard#: Expires: _ VIN#:
Authorized Signature:
REVISED B252DD5
`moo` .ne
.00050Valley
11707 E Sprague Ave Suite 106 ♦ Spokane Valley WA 99206
509.921.1000 ♦ Faxc 509.921.1008 ♦ cityhall@spokanevaltey.org
Residential Plan Submittal Minimums
EV Completed Building & Mechanical application with: Accurate address, Parcel
Number and/or Legal Description, description of work, owner and contractor
information, signature, and date.
El/ Two sets of plans including Site Plan, elevations, floor plans, foundation plans
With details, roof plan, framing plans & details.
Show the height of any proposed buildings or accessory structures.
[� Floor plan for each floor Dimension to scale (minimum 1/8").and label each
Room (including sq. footage of house and garage on plans) Show each
level of existing house and square footage of any additions.
•
❑ All braced wall panel types: show locations and details of installation, including
engineered design.
Q Egress windows: Provide at least one window or exterior door approved for
Emergency escape or rescue from a basement and in every room for sleeping.
Et/ Smoke detector locations
137 22" X 30" attic access location
i2 18" X 24" crawl space access: •
❑ One-hour separation detail: between house and garage •
E( Floor framing details: Joist type, size, spacing and installation details
[g/ Roof framing plan and details
ID/ Furnace and hot water heater location.
. ❑ All header locations: type, size, and connections
1 Foundation plan
ii Insulation information
APR 25 2006 10 51 FR TO 3241567 P.03/03
-
-
40 Spokane Valley,WA 99206
PERMIT FEB:
4.00111. �� �� (509)63: �.y. PAX:(509)688-0037
C.omaap:i y Development Rte'- a-� j `:, --J V_
,..._./.,
Residential Construed APR 10 N on.struction o Accessory Bldg
Permit Application• ��.'on/Remodei n Deck
,_ — ' ' L .
SITE Ar I IR.ESS 1r 7, A —7- .r i -
ASSESS):itS PARCEL NO: o2 —.J r S! LEGAL DESCRIPTION: C f1DDFr7T ADD. 1,„5-- A }
.litI 1n 1 min. .. 1''-+ 1 p j.,f C+,�'h eG",3'a Con t:J�: . (' :. .- : . �)
Name:. k1 I KL„_$4 •S I; Name:
Address: 12,/a ail X i x lis--.1—— Address: .
'y_a)C L Zip: 99a) 3 city: Zip:
nixie:3 i bop/3 Fax •, Phone: Fax:
-- Lie No: Exp.Date:
•
'__ 2, 51 0 ; ,.::,r. P w� 4- I, City Business Lie No:
Name: LII 44,- /M' [ '�
- -
Phone:_- .1-41-1.4e.
Describe the scope of work in detail: Cost of Project: $ /a,5;pOO 2-
, ,,rt f!A/ �t tp'--✓Ti4i I�4J crzatic i/ori
*****k *******The following MUST be complete_: (write N/A if not applicable ********************t*
HEIGHT T D PEAK: DIMENSIONS' #OF STORIES: TOHAB ABLE SPACE
- -4,r Sot ' x40' L I .
MAIN FU)DR TO SQ. 2""FLOOR SQ, FTG: UNPIN BASEMENT SQ. FTG: 'IMPERVIOUS SURFACE
,1
FTG: �d u / ` ---�'� i,6' o AREA:
�.
FINISHED BASEMENT GARAGES= DECK/COATIO SQ. FTG: 30% SLOPES ON
SQ.FT 3: dy 10 3 PROPERTY:
#OF BIR 4tooMS: CONSYRUCTION TYPE: HEAT SOURCE: SEWER OR
op
..._J2..- F4.4 me)) 6",&c Fit tNA.c&:—
DISCLAIM E 3
The perrnit i I verifies,acknowledges and agrees by their signature that 1) If this penult is for construction of or on a dwelling,the
dwellIng ism,II be served by potable water, 2) Ownership of this City of Spokane Valley Permit inure to the property owner. 3) The
signatory IF. he property owner or has permission to represent the property owner in this transaction. 4) AP construction is to be done
In foil=FR;ince with the City of Spokane Valley Development Code. Referenced codes are available for review at the City of
Spokane V si ey Permit Center. 5) This City of Spokane Valley Permit is not a permit or approval for any violation of federal,state or
local lave::,.x des or ordinances.6) Plans or additional Information may be required to be submitted,and subsequently approved before
- this appGa kin can be processed. _
•
Signature „0/0Date '1l 5' D 4.
Method of s rymenL (Faxed permit applications Mt only be accepted with major bankcard)
0 Cash ❑ Check 0 Mastercard 0 VISA ❑ Other
Bankcant I: Expires: _ VINO:
Authorized Signature: •
mow 92.9tao IS
** TOTAL PAGE.03 **
Permit Center
Spo°'kane 11707 E Sprague Ave,Suite 106
Valley Spokane Valley,WA 99206 PERMIT NUMBER:
(509)688-0036 FAX:(509)688-0037 PERMIT FEE:
Community Development www,spokanevalley.ors
Plumbing Permit Application n Commercial 94 Residential
SITE ADDRESS: _ to 763 %4l 7r) r4 UP S Pail ALL 1M 1. y 4-).4 99 21
Building Owner
��Ap
Name: rn r^''[� l'tS Z( Phone:914,'las--3o1 3 Fax:
Address: State: Zi
t3oX 1363-3 S Po X�W P Vi4c `�`y t✓A . v'99
Contractor C
Name: J Phone: Fax:
Address: City: State: Zip:
License No: City Business Lic:
Contact
Name: Phone:
DESCRIPTION OF WORK #OF UNITS X COST = TOTAL AMOUNT
1 TOILETS WATER CLOSET,BIDETS vt X $6.00 =
2 URINALS X $6.00 =
3 TUBS • X $6.00 =
4 SHOWERS(PER TRAP) BATH,STALL,ON-SITE BUILT 1 X $6.00 =
LAVSBASINS,BAR,FLOOR,KITCHEN,
5 SINKS LAUNDRY,UTILITY,JANITOR,PHOTO, X $6.00 =
X-RAY,FOOD,PREP/CULINARY MEAT
6 DISHWASHER X $6.00 =
7 CLOTHES WASHER X $6.00 =
8 GARBAGE DISPOSAL 1 X $6.00 =
9 WATER SOFTENER X $6.00 =
10 ELECTRIC HOT WATER TANK NOTE: IF GAS,SEE MECHANICAL X $6.00 =
AREA,CASE,COIL TRENCH,
11 FLOOR DRAINS CONDENSATE , X $6.00 =
12 ROOF DRAINS/OVERFLOW DRAINS X $6.00 =
13 FOUNTAINS,DRINKING X $6.00 =
WATER PIPING/DRAIN-IN WASTE, NSTALLATION,ALTERATION,REPAIR,
14 VENT,PLUMBING,REVERSAL REVERSALS X $6.00 =
15 SEWAGE EJECTOR GRINDER,SUMP PUMP X $6.00 =
ICE AN/OR COFFEE MAKER,HOSE BIB,
16 WATER USING DEVICE STEAMER X $6.00 =
PROOFER,CARBONATOR,SWAMP
COOLER
VACUUM BREAKER,CHECK VALVE,
AND R.P.B.P.D.FOR: VATS,TANKS,
17 CROSS CONNECTION DEVICE BOILERS X $6.00 =
GREASE TRAP,SAND TRAP,
18 INTERCEPTORS CHEMICAL HOLDING TANK X $6.00 =
19 MEDICAL GAS(per outlet) NITROUS,OXYGEN X $6.00 =
20 MISCELLANEOUS PLUMBING FIXTURE X $6.00 =
21 PRIVATE SEWAGE DISPOSAL/SYS X $20.00 =
22 INDUSTRIAL WASTE INTERCEPTOR X $15.00 =
SUBTOTAL
METHOD OF PAYMENT:
PROCESSING FEE
['CASH 0 CHECK 0 VISA 0 MC EXPIRES: $35.00
Card# VIN: TOTAL PERMIT FEE DUE:
AUTHORIZED SIGNATURE:
REVISED 8/26/05
_ Permit Center
Spo`rkane 11707 E Sprague Ave,Suite 106
Valley Spokane Valley,WA 99206 PERMIT NUMBER:
(509)688-0036 FAX:(509)688-0037
Community Development www.spokanevailev,ora PERMIT FEE:
Mechanical Permit Application (l Commercial ['4 Residential
f
SITE ADDRESS: I' 703 4,-, /� -
SpOieitiJ - (id . 9'9'2/ -z--
Building
Building Owner
Name: Phone: Fax:
Address: City: State: Zip:
Contractor
Name: Phone: Fax:
Address: City: State: Zip:
License No: City Business Lic:
Contact
Name: Phone:
DESCRIPTION OF WORK #OF UNITS X COST = TOTAL AMOUNT
1 FUEL BURNING APPLIANCE Equal to or less than 100,000 X $12.00 =
2 FUEL BURNING APPLIANCE More than 100,000 X $15.00 =
3 UNLISTED APPLIANCE(Additional Fee) Equal to or less than 400,000 X $50.00 =
4 UNLISTED APPLIANCE(Additional Fee) More than 400,000 X $100.00 =
5 USED APPLIANCE(WSEC min.AFUE rating) Equal to or less than 400,000 X $50.00 =
6 USED APPLIANCE(WSEC min.AFUE rating) More than 400,000 X $100.00 =
7 BOILER/REFRIGERATION 1-100M BTU X $12.00
8 BOILER/REFRIGERATION 101-50DM BTU X $20.00 =
9 BOILER/REFRIGERATION 501-1,000M BTU X $25.00 =
10 BOILER/REFRIGERATION 1,001-1,750M BTU X $35.00 =
11 BOILER/REFRIGERATION More than 1,750M BTU X $60.00 = ,
12 GAS LOG,GAS INSERT,GAS FIREPLACE X $10.00 =
13 RANGE I X $10.00 =
14 DRYER j X $10.00 =
15 FUEL BURNING WATER HEATER X $10.00 =
16 MISC.FUEL BURNING APPLIANCE X $10.00 =
17 GAS PIPING(each outlet) X $1.00 =
18 DUCT SYSTEMS X $10.00 =
19 VENTILATING FANS X $10.00 =
20 AIR HANDLER(DOES NOT include ducting) Equal to or less than 10,000 CFM X $12.00 =
21 AIR HANDLER(DOES NOT include ducting) Greater than 10.000 CFM X $15.00 =
22 EVAPORATIVE COOLERS X $10.00 =
23 TYPE I HOOD X $50.00 =
24 TYPE II HOOD X $10.00 =
25 HEAT PUMP/AIR CONDITIONER 0-3 TON X $12.00 =
26 AIR CONDITIONER 3-15 TON ' X $20.00 =
27 AIR CONDITIONER 15-30 TON X $25.00 =
28 AIR CONDITIONER 30-50 TON X $35.00 =
29 AIR CONDITIONER More than 50 TON X $60.00 =
30 LPG STORAGE TANK X $10.00 =
31 WOOD OR PELLET STOVE/INSERT
f X $10.00 =
32 WOOD STOVE-FREE STANDING X $25.00 =
33 REPAIR&ADDITIONS X $15.00 =
34 VENTILATION SYSTEMS X $12.00 =
35 VENTILATION MECHANICAL EXHAUST X $12.00 =
36 INCINERATOR-RESIDENCE X $19.00 =
37 INCINERATOR-COMMERCIAL X $22.00 =
METHOD OF PAYMENT: SUBTOTAL
❑CASH 0 CHECK 0 VISA 0 MC EXPIRES: PROCESSING FEE $35.00
CARD#: VIN: TOTAL PERMIT FEE DUE:
AUTHORIZED SIGNATURE:
REVISED 8/26/05
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