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Home My WebLink AboutPermit Septic Tank 1981-9-25 INSPECTION LINE 726-3769 CITY OF SPRINGFIELD COMBINATION APPLICATION/PERMIT INFORMATION LINE , 726-3753 Job Address ~6 - ;?,eCJ/9/Ju./A Y , ENERGY SOURCES: Heat Water Heater Range Value of Work: I Sq. Ftg, Main Sq. Ftg. Access. Sq. Ftg. Other _New_Add_Alter_Rep. _Fence_Demo_Change/ Use _Other Owner '" S': SOI-fMEED/~J~ 33R--M/AJr &/C!r€/LJi6 CJ ,/P, / L 0C2 n./s::", 2Building Permit Info: Describe Work (i.e., Build Single Phon'V'Q.::l...o :,. / 9-~ 1 zt:amily Residence With At~ched Garage) ...... q~LJCJ4 5elA/ek? 'i3-4/'/uiY (tUi'J ~ /&:?J " ~ ~ ~ \\) legal Description Address Construction lender Address Phone DESIGN TEAM (name) (address) (lics. no.) (expires) (phone no,) Primary Structural Electrical Mechanical CONTRACTORS (nome) (address) (Iics. no.) (expires) (phone no.) plumbing / /I/a / General Electrical Mechanical PLUMBING ElECTRICAL MECHANICAL NO. FEE CHARGE NO, FEE CHARGE NO. FEE CHARGE SERVICES furnace/ burner to BTU's Appliance vent separate Stationary evap, cooler Vent fan with single duct Vent system aport, from heating or A.C. Mechanical exhaust h'ood and,duct,_ Residence of Each single fixture Relocated building (new fix, additional) S.F, Residence', (1 both) sq. ft. New circuits, alterations or extensions Duplex (1 bath) each Temporary Construction Additional bath Amps. Water... serv.i~~ ._. ~ ___--.._.~_~' _~_ _ ...... -o:..._AJ"'-_ :; 4'-- :~--- .__~...-..-e.:...".,_ ~''1 Sewer . Wood stove/ heater Storm Sewer FEEDERS HeQt Pump, Air handler to 10.000 CFM , Air handler"over 10,000 CFM Amps. ISSUANCE OF PERMIT TOT~lCHARGES~ ~~~' TOTAL CHARGES TOTAL CHARGES WHERE STATE LAW REQUIRES that the Electrical work be done by the Elactrical Contractor, the electrical portion of this permit shall not be valid until a label has been signed by an Electrical Contractor and attached to the electrical panel. I HAVE CAREFUllY EXAMINED the completed application for permit, and do hereby certify that all information hereon is true and correc.!, and I further certify that any and all work performed sholl 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 herin, and that NO OCCUPANCY wHl be made of any structure without the permission of the Building ,Division. I further certify thot my registration with, the Builder's Boord is in full force and elffect 0 s required by ORS 701.055, that if exempt the basis for exemption is noted heron, and that only subcontractors and employees who ore in compliance with ORS 701.055 will be used on this project, Basis for Builder's Board exemption: NAME (please print) C.fl5i,t:::L[ -K' J oh,n<:'+(lr") SIGNATURE (fi~ ~~~ FOR OFFICE USE ONLY {/ J_DATE 9~/fl 1 f Zone Type/ Canst Units Sq. Ftg. Main Fire Zone Bedrooms Occy load Sq. Ftg. Access Flood Plain <;torie' Occy Grour' Sq. Ftg. Other BUilDING PERMIT Plan Ck. Camm/lnd Charges and 65%/ Bldg Per Fee Surcharges Plan Ck. Res 30%/ Bldg Per Fee PLUMBING PERMIT Charges and Fence Surcharges Demo ElECTRICAL PERMIT Charges and Sidewalk Surcharges AI C Paving MECHANICAL PERMIT Charges and Curb Cut Surcharges -------- Value x Value x Value TOTAL VALUATION Systems Development Charge (1.5%) Total Comb. Permit I I I TOTAL COMBINATION APPLICATION/PERMIT (CAP) I. Applicant to furnish A. Job Address B. Legal Description 1. example-tax lot 100, Lane County Map Reference 17 03 43 2. example-Lot 1. Block 3, 2nd Addition to Springfield Estates C. Name, etc. of owner and construction lender D. Energy Sources 1. example-heat/electrical ceiling/or forced air gas 2. example-wciter heater/electrical/or solar E. Square footage or valuation, etc. 1. exampfe-1250 sq. foot house, 500 sq. foot garage 2. example-if new project, check new-if addition, check add, etc. F. Building permit information: 1. example-construct single family house with an attached garage 2. example-remodel existing garage into family room 3. example-convert single family residence into restaurant (change of use) G. Value of work as defined in Section 303 (0) of the Structural Specialty Code H. DESIGN TEAM AND CONTRACTORS To avoid design or construction delays, Building Division Staff must be able to contact appropriate persons regarding design information or job site corrections, etc. II. Abbreviated Plumbing, Mechanical & Electrical Schedules A. Except where blank spaces occur in the description portion of the Mechanical and Electrical Schedules, the applicant need fill-in only the No. Boxes adjacent to the appropriate item(s) to be installed B. Full Plumbing, Mechanical, and Electrical Schedules are available at the Building Division 1. To conserve space on the permit form the schedules have been abbreviated 2. If the item(s) to be installed are not covered on the abbrevi- ated schedules you should consult the full schedules C. BUILDING DIVISION STAFF WILL Fill OUT ALL FEES AND CHARGES ON THE SCHEDULES III. Applicant to sign and date Whenever possible, the initial application will be used as a worksheet only. Where possible, Building Division Staff will prepare a typewritten copy and return it to the applicant at the time the actual permit is issued for his signature. IV. Fees and Charges Plan check fees are due and payable at the time of the application, and no plans will be processed until these fees are paid. All other fees and charges are due and payable when the permit is issued. V. FOR OFFICE USE ONLY PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY: AdditionClI Project Information: PLANS REVIEWED BY: nam'" 'iignaturp Permit Clerk ..;RMIT VALIDATION rl'1te