HomeMy WebLinkAbout1619 S Butler St - Engineering
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CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY DEVELOPMENT . - BUILDING DMSION
321 EAST 5TH STREET, PORT ANGELES; WA 98362
Application Number
Pin,number . . . .
Property Address
ASSESSOR PARCEL NUMBER:
Applicatioh description
Subdivision Name
Property Use . . _ .
Property Zoning . . ....
Application valuation
04-00000341 Date
.264235
3.619 S BUTLER ST
06-30-00-4-4-0080-0000-
RES MANUFACTURED HOME
5/06/04
RS9 RESDNTL SINGLE FAMILY
75772
Owner
Contractor
STRAIN, KENNETH L
23323. GILMORE STREET
WEST HILLS CA 91307
OWNER
. Structure Information
Construction Type
Occupancy Type
Other struct info
3.680SF MANF W/DETACHED 720SF GARAGE
TYPB V NON-RATBD
SINGLB FAM & CONGREGATES
TOTAL % LOT COVERAGE
EXISTING LOT COVERAGB
LOT SIZE
PROPOSED LOT COVERAGE
TOTAL LOT COVERAGE
NUMBER OF UNITS
21.00
1.00
11400.00
2400.00
2400.00
1.00
-........
~
~--------------------~-----~---.---------------------~~._-------------------
Permit
Additional'desc
Permit Fee
Issue Date
Expiration Date
DRIVEWAY INSTALLATION
'--'"
-.Q
145.00
5/05/04
11/01/04
Plan Check Fee
valuation
.00
o
BASE FEE
Extension
145.00
~
Qty unit Charge Per
- -.. - - - - - - - -- - ":" -- --- - -- .""''';;',--'' ....... - ---;..--- -------... ....;....;...;- - - - - --'. - - - - - ---. - - - - - - ~ '-..
Permit
Additional desc
Permit Fee
Issue Date
Expiration Date
SANITARY SEWER HOOK UP
95.00
5/05/04
11/01/04
Plan Check Fee
Valuation
.00
75772
~
t
Qty Unit Charge Per
1.00 95.0000 BA SAN'SEWER HOOKUP
Extension
95.00
---------------------------------------~----------------~-----------------~-
Special Notes and Comments
Proposal will allow placement of a manufactured home with
detached garage in the RS-Slzone for total lot coverage of
21%. Setbacks are good for the zone. No land use issues
are noted.
Building address sign shall. not be less than 6" & not more
than 12" in height. Numbers colors must 'contrast with wall
color they are mounted on. lOrd. 14.36.050-E)
When roof gutters are installed, drains will located in dry
wells or piped to approved storm drain locations.
Manufactured home must be pit set so that no more than 12.
of skirting is visable above grade.
Electrical load calculations and elctrical permits are
required.
Other Fees
SEWER SYSTEM DELV CHARGB
745.00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities..private and public improvements. This permit becomes
null and void if work or construction authorized is notcommenced within 180 days, if construction or work Is suspended or abandoned
for a period of 18.0 days after the work as commenced, or if required inspectIons h~ve not been requested Within 180 days from the last
Inspection. I hereby certify that I have read and examined this application and know th~ same to be true and correct. All provisions of
laws and ordinancesgoveming this type of work will be complied with whether'specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any state or local law regulatirig construction or the performance of
construction.
olJ F //E
Signature of Contractor or Authorized Agent '
Date
Signature of Owner (if owner is builder)
Date
T:\PLANNING\FORMS\1102.1S [1111412003]
CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
, : ' , .' "'-." .' '-.' - .' .'.", .' - ,.' -.' .'.",.'.' -.' '! " .' '.: " : ' , '"..' ~
BUILDING PERMI1HNSPECTION RECORD
PLEASE'rRO\'ID~'^,MINIMUM 24 HOUR.N91WE. IT IS ~L,4w.FULTO COYE~1N~UI4TE Oll-"CONCEALA.NY~OQ$BEFORE
INSPECTEDANpA.CCEPTED'POSf,PF;RMIT IN A CONSPICUOQS LOCATION'" '. . .
KEEPi~ERMiifCARD AJiIDAPPR.oVED PLANSj\T'10BSITE" "...... i.i;,;' I',r
v, ,-, v.,
INSpEcTIoN TYPE '~ATE ACF~PTED COMMENrs . ...
:":.,~,
YES) ~:t,,',J,," '.
'. [. NO };' "
,-",
FOUNDATIQN; ;; ,',1'<
. '.' I
FOOTINGS ,.' j .', ..',
WALLS .'
FOUNDAll0N~\DRA1NAGEIDOWN SPOUTS "'i' T ..', " r
ELECTIU~ (LIGHT Dr;P1) SEPARATE p~~# ,X; .
ROUGH~JlIi . 1..",;0 I I '. . .<
PLUM~IN~' ""'.>.: . " .' .... '.',
.
UNDERfI:.OOR'SLAB -, .' "" .' . ,
,.RqUGHfJi-l' '. .' :"
WATERLINE (METER TO BLOG) . ,.... ,"r". I'
GAS L~ ..C, : h I:" '. ,
,.
BACKMW' WATER . ;:;7 , ".ii:, ,.>':. ..... .,. '..' j
. {c,
.," . .,. .... ..
AIRS~
WALLS .' . .
CEILING I "',' - I '.. '. .... I :. I. '.
. ...
. . "
FRAMING . .. ,I.
JOISTS I GIRDERS .0'
.. SHEAR wA,wHOLDl)OWNS . .,
.
WALLS' ROOF 'CEILING C'
,.'
DRYWALL (INTERIOR BRACED PANEL ONLr> . ,
T-BAR .' ,'.. " . '0 ,<. '. f
.
INSULATION , ; .,
SLAB ....... '. r .
wAIl i FLO<>R." CEiLiNG ..d" . ". ." I :
MECIIf\NlCAL .. .;,<,~;;/ '. .:.'
HEAT PUMP .' . .
GAS LINE ., I
. .
WOOD STOVE I PELLET, CHIMNEY .
HOOD' DUCTS ." ., ". -co
."
PW UTILITIES , SITE WORK (Engineering Divisi~) SEPARATE PERMIT #'$; I "
W ATERLINEI.METER '.
SEWER <;;ONNECTION .' [
,.' . , I
SANITARY . .
.'.
STORM .'
PLA\IIN~g;J)EP,l'. SEPARATE PERMIT #'5 '. . .... SEPA:
.
PAIUg~~!~JiJ1N~ . ESA:
LANDSOAPiNG4 . -;- -;- . ~..'"
" . "',", 1.',:;',' 0; '_"':r~ " 'j . -,. . ','~:':* - " . .' .' t;i-. ..,' ,'''''"' ^ SHp~~: .
< ,.) i" 'ii', it", . .' 'J1~~H'1~!'Elg~S ~U~P~9,R ~ OCCU~~J;Y(Y~E!,< " , I .... .....
. ..
RESIDENTIAL '" 1" Dm;: YES " NO . €OMMER~IAI. DATE . ".A<::pu"Il~
. ..... .' " , "YES 'NO
.:"-,
:. 417-413S: ...,., J i-<"" " , i' '" :,,; .
ELECTRIC,q - LIGHT DEPT. ELECTRICAL
'. . UGHT DEPT
CONSTRUCTION R. W., PW, CONSTRUCTION -.R.W. .
ENGn-iEERJNG, 417-4807 PW , ENGINEERING .... : .
:':C"'-"~ I <"
FIRE ^ ' 417-46S3 FIRE DEPT. . ~'. ., .'
", -.- . .
PLANtlING,I>m>T. '':-- - , >0. -." '", l
417-47S0 PLANNING DEPT.
BUn.DIJIlG;t .." , 417-481S .' .. . BlnLOTh/(j'" .... ''C ,;. ,. '" , I,'" , .:'
'>
T:\PLANNING\FOR.MS\II02.IS [II 1412(03) .
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CITY OF 1>ORTANGELES
DEPARTMENT OFCOMMUNITYDID'13~()PlvfENT -BlJILDING DIVISION
32i EAST STH STREET, PORt ANGELES, WA98362
Application Number . . . . . 04-00000341'
Pin number " .. . . .264235
pag~ 2
Date 5/06/04
Other Fees
STATE SURCHAR~E
PW WATER SYSTEM USE FEE
4.50
" 1025.00
Fee summary
Charged
Paid Credited
Due
-PermiEFee ToEai
Plan ,Check Total
Other Fee Total
Grand Total
240.00
.00
1774.50
2014.50
240.00 .00
.00 .00
1774.50 .00
2014.50 .00
.00
,00
.00
.00
.pate
Separate P,~~are requirEld fo~ electrical.'Nor~'~~~~i,~~o[~line! ~S~, ytl}i~~~'H~Ya.te ~nd l>u.blic}fJ'IPl:9~~rpE:)n~"+JJ1h).~rfu;~~~,C911l~~
null and void if wO,rk or construction authorized Isnptcommenced wlthlrr1..~.g,:(f,a~.if construction or W9r!t}I,f?~lJsp(lnd',~',pr;"~Clndonfiltl
for a pM()d of189itla~afterthe work as commenc.~~.()r~r4!9ulred inspe~'I,~ns.,have not been requestetl)\'i~i~18~,~..~frPT ~~Jast
insp8fiion. I,herebycertifythatl haveread and~XEi~i~ed !his applica~9n'~nd-kriowthe same tobettueandcolTElct:!9lprpvlsions ()f
laws, aild orditl~nc;~s gov~ming this type of work'Ni,!I:~~~l11plied w1thY/n~g:r~r'sp~cifled herf}ln or not. The 'granting of-a' pt3nnitdoes nqt
presume to give authority to violate or cancel the'proylsions of any state;'orJocallaw regulating construction'orthe performance of '
construction.' ,'" ,
Signature 'of Contractor or Authorized Agent
'Sigra,~ure()f Owner (if oWner Is builder)
Date
T:\PLANNING\FORM~U02.1S[1111412003]
BlITLDINGPERMIT INSPECTION RECORD
...
CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL A/VYW()Rl( BEFORE
INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION.
. KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE
:
INSPECTION TYPE DATE ACCEPTED COMMENTS
I YES NO
FOUNDATION:
FOOTINGS
WALLS
FOUNDA nON DRAINAGEIDOWN SPOlITS
ELECTRICAL (LlGHTDEPT) SEPARATE PERMIT: #
ROUGH-IN ,
PLUMBING
UNDER FLOOR / SLAB
ROUGH-IN
WATER LINE (METER TO BLDO)
GAS LINE
BACK FLOW/WATER
AIR SEAL
WALLS
CEILING I I I
FRAMING
JOISTS / GIRDERS
SHEAR W ALLlHOLD DOWNS
WALLS / ROOF / CEILING
DRYW ALL (INTERIOR BRACED PANEL ONLY)
T-BAR .
INSULATION
SLAB
WALL / FLOOR/ CEILING -,
MECHANICAL
HEAT PUMP
GAS LINE
WOOD STOVE / PELLET / CHIMNEY
HOOD / DUCTS
PW UTILlTI~ / SITE WORK (Engineering Division) SEPARATE PERMIT #'5:
WATERLINE I METER
SEWER CONNECTION
SANITARY .
STORM
PLANNING DEPT. SEPARATE PERMIT #'5 SEPA:
PARKINGlLIGHTING ESA:
LANDSCAPI~~ SHORELINE:
'. FINAL.INSPECTION.S REQUIRED PRIOR TO OCCUPANCYIt!SE,
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
'. YES NO
.
ELECTRICAL - LIGHT DEPT. 417-4735 ELECTRICAL
. J LIGHT DEPT
CONSTRUCTION R. W.I PWI fJJJ IMI,$' ~? CONSTRUCTION - R. W.
ENGINEERING 417-4807 PW / ENGINEERING
FIRE 417-4653 -, FIRE DEPT.
. '.
PLANNING DEPT. 417-4750 PLANNING DEPT.
BUILDING 417-4815 BUILDING
T:\PLANNlNG\FORMS\II02.15 [11/1412003]
~ .ORT ~
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CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number
pin number
Property Address
ASSESSOR PARCEL NUMBER
Application description
Subdivision Name
Property Use
Property zoning
Application valuation
04-00000341 Date
264235
1619 S BUTLER ST
06-30-00-4-4-0080-0000-
RES MANUFACTURED HOME
5/06/04
/&/q!;~
RS9 RESDNTL SINGLE FAMILY
75772
Owner
Contractor
STRAIN, KENNETH L
23321 GILMORE STREET
WEST HILLS CA 91307
OWNER
Structure Information
Construction Type
Occupancy Type
Other struct info
1680SF MANF W/DETACHED 720SF
TYPE V NON-RATED
SINGLE FAM & CONGREGATES
TOTAL % LOT COVERAGE
EXISTING LOT COVERAGE
LOT SIZE
PROPOSED LOT COVERAGE
TOTAL LOT COVERAGE
NUMBER OF UNITS
GARAGE
21 00
1 00
11400 00
2400 00
2400 00
1 00
Permit
Additional desc
Permit Fee
Issue Date
Expiration Date
DRIVEWAY INSTALLATION
145 00
5/05/04
11/01/04
plan Check Fee
Valuation
00
o
Qty
Unit Charge Per
BASE FEE
Extension
145 00
Permit SANITARY SEWER HOOK UP
Additional desc
Permit Fee 95 00 Plan Check Fee 00
Issue Date 5/05/04 Valuation 75772
Expiration Date 11/01/04
Qty Unit Charge Per EX~'
1 00 95 0000 EA SAN SEWER HOOKUP 95 00 .
------------------------------------------------------------------- --
Special Notes and Comments
Proposal will allow placement of a manufactured home with
detached garage in the RS-9 zone for total lot coverage of
21% Setbacks are good for the zone No land use issues
are noted
Building address sign shall not be less than 6" & not more
than 12" in height Numbers colors must contrast with wall
color they are mounted on (Ord 14 36 050-E)
When roof gutters are installed drains will located in dry
wells or piped to approved storm drain locations
Manufactured home must be pit set so that no more than 12"
of skirting is visable above grade
Electrical load calculations and elctrical permits are
required
(;) t1li7l, j7J 111!7it
f~
/qqr
Other Fees
SEWER SYSTEM DELV CHARGE
745 00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced or if required inspections have not been requested within 180 days from the last
inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of
laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of
construction.
Signature of Contractor or Authorized Agent
Date
Signature of Owner (if owner is builder)
Date
T'IPLANNINGIFORMSII102.]5 [1]/14/2003]
BUILDING PERMIT INSPECTION RECORD
CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE
INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCA nON
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE.
INSPECTION TYPE DATE ACCEPTED COMMENTS
YES I NO
FOUNDATION
FOOTINGS
WALLS
FOUNDATION DRAINAGE/DOWN SPOUTS
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT #
ROUGH-IN
PLUMBING
UNDER FLOOR / SLAB
ROUGH-IN
WATER LINE (METER TO BLDG)
GAS LINE
BACK FLOW / WATER
AIR SEAL
WALLS
CE]LlNG
FRAMING
JOISTS / G]RDERS
SHEAR WALL/HOLD DOWNS
WALLS / ROOF / CEILING
DR YW ALL (INTERIOR BRACED PANEL ONLY)
T-BAR
INSULATION
SLAB
WALL / FLOOR / CEILING
MECHANICAL
HEAT PUMP
GAS LINE
WOOD STOVE / PELLET / CHIMNEY
HOOD / DUCTS
PW UTILITIES / SITE WORK (Engineering Division) SEP ARA TE PERMIT #'s:
WATERLINE / METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT SEPARATE PERMIT #'s SEPA,
P ARKING/LlGHTING ESA.
LANDSCAPING SHORELINE.
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTRICAL LIGHT DEPT 4]7-4735 ELECTRICAL
LIGHT DEPT
CONSTRUCTION R.W / PW/ CONSTRUCTION R.W
ENGINEERING 4] 7-4807 PW / ENGINEERING
FIRE 4] 7-4653 FIRE DEPT
PLANNING DEPT 4] 7-4750 PLANNING DEPT
BUILDING 4] 7-48]5 BUILDING
T \PLANNINGIFORMSI] 102.15 [] I1I4/2003]
~f'or:~ ~
$4.0~~~
r'la
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CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number
Pin number
04-00000341
264235
Page 2
Date 5/06/04
Other Fees STATE SURCHARGE 4 50
PW WATER SYSTEM USE FEE 1025 00
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 240 00 240 00 00 00
Plan Check Total 00 00 00 00
Other Fee Total 1774 50 1774 50 00 00
Grand Total 2014 50 2014 50 00 00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of
laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the proviSions of any state or local law regulating construction or the performance of
construction.
Signature of Contractor or Authorized Agent
Date
Signature of Owner (if owner is builder)
Date
T'IPLANNINGIFORMSI] 102.15 [] ]/]4/2003]
BUILDING PERMIT INSPECTION RECORD
CALL 417-4815 FOR BUILDlNG INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE
INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCA nON
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE.
INSPECTION TYPE DATE ACCEPTED COMMENTS
YES NO
FOUNDATION:
FOOTINGS
WALLS
FOUNDATION DRAINAGE/DOWN SPOUTS
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT #
ROUGH-IN I I
PLUMBING
UNDER FLOOR 1 SLAB
ROUGH-]N
WATER LINE (METER TO BLDG)
GAS LINE
BACK FLOW 1 WATER
AIR SEAL
WALLS
CEILING
FRAMING
JOISTS 1 GIRDERS
SHEAR WALL/HOLD DOWNS
WALLS 1 ROOF 1 CE]LING
DR YW ALL (INTERIOR BRACED PANEL ONLY)
T-BAR
INSULATION
SLAB
WALL 1 FLOOR 1 CEILING
MECHANICAL
HEAT PUMP
GAS LINE
WOOD STOVE 1 PELLET 1 CHIMNEY
HOOD 1 DUCTS
PW UTILITIES 1 SITE WORK (Engineering Division) SEPARATE PERM]T #'s:
WATERLINE 1 METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT SEPARATE PERMIT #'s SEPA,
P ARKING/LlGHTlNG ESA.
LANDSCAPING SHORELINE,
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTRICAL LIGHT DEPT 417-4735 ELECTRICAL
LIGHT DEPT
CONSTRUCTION R.W 1 PWI CONSTRUCTION R.W
ENGINEERING 4] 7-4807 PW 1 ENGINEERING
FIRE 4]7-4653 FIRE DEPT
PLANNING DEPT 4]7-4750 PLANNING DEPT
BUILDING 4]7-4815 BUILDING
T IPLANNINGIFORMS\1102.15 [] 11]4/2003]
~
APPLICATION FOR WATER
City Water Department
Port Angeles, Wash. S - 5"
-i ":;,.)__ \\~\
\
2CD'-!
, fl'=
I hereby apply for water to be furnished in accordance with rates and rules of the City
for the following premises L.. ..J I . D8~_7~'Z."Z.. (p~/-:~<U1-
~l'enYle:rn L.-ST~I\4 $1$6 ,7Q ~
Name of Applicant ~ I ',-,-, r.; iZr't \\ ~ '03 j.t::7-'7 tit Al-J..t:>
. Q ~\ \ \.. _ :;2.~ ~Z-I 4t!p?()/'E- 'ST.
Address I It \ \ \~{\ \ '(?~V" S- \ wesl-Jl, JI~ C A-
\ 6/307
Renewal 0 New Service~ BI~ Lot~ Add EA4 u-:3 L-A-f 1<:.
'57 II 1""',\.L:t i'lo8qg~b f4cl,~
Size of Service \ '" - I r Meter Number':'~ 0/54 000000
Service Left O~ Service Left Off 0 Signed
Installed by
fe ,,'wi \\ ~ 04-5'1/ 1> &40iKl -+--1> IO"ZS DO
Remarks
1
\AI
O<l
-
.....
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+" ~ ~ 1
E
s
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
INSPECTION REPORT. .
REQUEST
Date
___ Time_______
Received by
(phone, person)
Location of Work to be inspected / b /9
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one)
-6 L' T L.. ElL ,:s..-:
Phone No
Permit No
Sewer Foundation Framing Chimney Plumbing Final Sewer Excav Other
o1-3CJI
~
Inspected
Remarks
INSPECTION NOTES
7/~/OLt
,
Date
Time
/ 3c\ ';)'1
By ,--J 4NlJDEuJ:;'
RESTORATION REQUIRED
is L DC-\
YES
NO
4 S{
~b =-'- LI.-" ".~ u----
-----.J
r-"Z...'- 4..(P~c...
p
4 s'" ~
\)'l.-,y.,..'V'
GI\.t~.:tIN4
s-s {)'\~
c......[ ;;:, S' ' oe Pih
LvLJ- ~ ~b 4
SURFACE RESTORATION
SURFACE TYPE D Unimproved 0 Gravel 0 Asphalt 0 PCC
o Other
[] Repaired by City
[] Repaired by Permittee
[] No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)