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HomeMy WebLinkAboutPermit Building 2013-9-19 SPRINGFIELD- 225 Fifth St kit,- CITY OF SPRINGFIELD Springfield,OR 97477 Phone: 541-726-3753 ` OREGON Building / Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR2013-01864 www.springfield-or.gov permitcenter @springfield-or.gov PROJECT STATUS: Issued ISSUED: 09/19/2013 • EXPIRES: 03/18/2014 STATUS DATE: 09119/2013 APPLIED: 08/20/2013 SITE ADDRESS: 2991 YOLANDA AVE,Springfield, OR 97477 SCOPE: Shop ASSESOR'S PARCEL NO: 1702193300804 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: Garage/Shop with bedroom/bathroom above OWNER: LEWIS RICHARD A&LARSON-LEWIS LAURIE L Phone Number: ADDRESS: 81840 LOST CREEK RD DEXTER OR 97431 CONTRACTOR INFORMATION - Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 08/01/2025 Electrical Contractor OWNER CCB 000000 08/01/2025 L INSPECTIONS REQUIRED II Inspections 1020 Zoning Setbacks 1110 Footing Footing: After trenches are excavated. 1120 Foundation Foundation: After forms are erected but prior to concrete placement. 1160 UFER Ground Ufer Electrical Ground: Install ground rod at footing and call for inspection in conjunction with footing and/or foundation inspection. 1260 Framing Framing Inspectierj: Prior to cover and after all rough in inspections have been approved.,yOJ v‘ki 1410 Underfloor insulation 1a�teQalegOn -"C) 1420 Insulation Vapor Barrier Veg. \-A k -ows an- gy2 osby 1430 Insulation Wall .��EN"\e5 ado eC.'(h elrh�.`u (idle 1-Fic't�cover. Pow 1 G p 1 \ clto e,i 00 c" 0 1440 Insulation Ceiling;61 ' \:\OP - \-u `at `g,ltituut�tion.�C Gr o�r to cover. 1520 Interior Shearwa IN, op?, "may O.St1 w v Aiii Before covering sheathing with finish materials. .11 N CPr cor3u 03?�. 1530 Exterior ShearwallO09�., ( we t\NOO -%O0 >;° �� • G at tOtnket is 1 . . - `.w\Q O,� 1540 Gypsum Board/Lath/D ye" Ge Drywall: Prior to taping. Lath/Plaster: To be made after all lathing and gypsum\< V cS� board, interior and exterior are in place, but prior to plastering. \_ • .• 1999 Final Building . Final Building: After all required inspections have been requested ncl q6e Act) the building is complete. e '(\\\ QA cite' \ .0.\\ R3 " o 0 � 00CAk� P i .P� � Nl P Springfield Building Permit 9/19/2013 10:13:48AM Page 1 of 2 SPRINGFIELD ' h,A 225 Fifth St : -- CITY OF SPRINGFIELD Spri ngfield,OR 97477 . t.a:c.,LAO Phone: 541-726-3753 OREGON Building / Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR201 3-01 864 www.springfield-ar.gov permitcenter @springfield-or.gov • 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 or 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. XI-2/.4,-C ?V '-/-.7 Owner or Contractor Signature Date Springfield Building Permit 9/19/2013 10:13:48AM Page 2 of 2 SPRINGFIELD CITY OF SPRINGFIELD • kir:____A 225 Fifth St '- ``OREGON TRANSACTION RECEIPT Springfield,OR 97477 541-726-3753 811-S PR2013-01864 www.springtleld-or.gov 2991 YOLANDA AVE permitcenter @springtield-or.gov RECEIPT NO: 2013002077 RECORD NO: 811-SPR2013-01864 DATE:09/19/2013 ;DESCRIPTION - - ,.. .-,.ACCOUNT-CODE/TRANSCODE.: -• - _%AMOUNT_DUE_,3 Planning-Minor Review- UGB 100-00000-425002 1231 286.00 SDC: Improvement Cost-Storm Drainage 440-00000-448028 1176 459.90 SDC: Reimbursement Cost-Storm Drainage 441-00000-448029 1177 316.26 SDC:Total Storm Administration Fee 719-00000-426604 1180 38.81 State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 29.43 Structural Building Permit Fee 224-00000-425602 1002 245.21 Technology fee(5%of permit total) 100-00000-425605 2099 12.26 TOTAL DUE: 1,387.87 • - - -, AMOUNT PAID {,�_f?AYMENT TYPE_� PAYOR__caSwER.oeowcssY a� _COMMENTS • - `-- - -______�-.,._..I Credit Card LEWIS RICHARD 1,387.87 015259 TOTAL PAID: 1,387.87 i Structural Permit Application SPRINGriELD - DEPARTMENT USE ONLY CITY OF SPRINGFIEED OREGOR s' -" ..?.,. ..e<>.. ._ ;'< d, .. l..;, da sw'^N`OREGON Permit no.: LII 2013 O(&6 225 Fifth Street•Springfield,OR 97477♦PH(541)726 3753•FAX(541)726 3689 . Date: a/zo//3 • This permit is issued under OAR 918-460-0030.Permits expire if work is not started within 180 days of issuance or if work is suspended for 180 days. x 1 s LOCAL'GOYER NMENT APPRO L a, r .,, "+ otia, t i a FEE SC HEDULE , ' R ,This project has final land-use approval. 1 tutianformn-r r !• A ,ni �.n _ Signamre: Date: // This project has DEQ approval. - (a)Job description: /arc j l / /90 Signature: Date: Occupancy Zoning approval verified: ❑Yes ❑No .Construction type: V it • Property is within flood plain: ❑Yes ❑No Square feet: ? ar `CATEGOR OF ONSTRUCION - Cost per square foot: %Residential ❑Government ❑Commercial Other information: • a-'.. ."4' :JOB- SITE'INFORMATION.AND„LOCATION 1' '-',,,,_„i Type of Heat C de 4 Job site address: 2 91/ �n�, 1/€1 ,c ire Energy Path: City: r 0' / G/d State: to./, ,(ZIP:y�fi�% ❑new Dalteration ❑addition Subdivision: O ,7/ici Lot no (b)Foundation-only permit? ❑f Yes ❑No Reference j 70 7 ' 9 7 jTaxlot OQ 2rQC/ Total valuation:J f lc r p ro c $78 o�— 7 > ei z ` r.PROPERTY 0NER x,.ark r 2 ii ee ' ri a s t . Name: r a/ ec�./7i,r (a)Permit fee(use valuation table): $ ,Y:S�( Address: 299/ , /a/Zoe° Ave. (b)Investigative fee(equal to[2a]): $ City: S�' /i,, ///i/ State: ,0„ ” ZIP:9'7y,) (c)Reinspection($ per hour): $ Phone: Syj - 3" 9-n no Fax: - - A/49 (number of hours x fee per hour) E-mail: cc/JS'9� �'x rO,y7 (d)Enter 12%surcharge(.12 x[2a+2b+2c]): $ L7 ±1 (e)Subtotal of fees above(2a through 2d): S Building Owner or Owner's agent authorizing this application: ""'' '-'ate .' SrT° "� ^*` 3'Plan revie fees �� : ''��x t-,`�� ��>:�;r. � � (a)Plan review(65%x permit fee[2a]) $ .. 3 7 Sign here: (b)Fire and life safety(40%x permit fee[2a]): $ /`� ❑This installation is being made on residential or farm property owned by (c)Subtotal of fees above(3a and 3b): $ me or a member of my immediate family,and is exempt from licensing 4r;Miscell wcet fre es x ^'eO °- requirements under ORS 701.010. _;,� _ _ (a)Seismic fee, 1°%(.01 x permit fee[2a]): S ..'. = ` ;CONTRACTOR INSTALLATIONy,3 i arat (b)Technology fee,5%(.05 x permit fee[2a]): S 17:1'% Business name: Z v TOTAL fees and surcharges(2e+3c+4a+4b):. S C/7U Address: ( [4, City . I State: ZIP: Phone: - - - I Fax: - - • • E-mail: - • CCB license no.: Print name: Signature: a SUB CODI RACTOR INFORMATIONS - =_ i Name CCB License fi Phone Number Electrical .Plumbing • Mechanical • SPRINGFIELD 1 225 Fifth St hAp ' '°' CITY OF SPRINGFIELD Springheld,OR 97477 '\` OREGON N Phone: 541-726-3753 Building / Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR2013-02079 www.springfield-or.gov permitcenter©springfield-or.gov PROJECT STATUS: Issued ISSUED: 09/19/2013 EXPIRES: 03/18/2014 STATUS DATE: 09119/2013 APPLIED: 09/16/2013 SITE ADDRESS: 2991 YOLANDA AVE,Springfield,OR 97477 SCOPE: Mechanical Only ASSESOR'S PARCEL NO: 1702193300804 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: ME-Garage/Shop with bedroom/bathroom above OWNER: LEWIS RICHARD A&LARSON-LEWIS LAURIE L Phone Number: ADDRESS: 81840 LOST CREEK RD DEXTER OR 97431 L CONTRACTOR INFORMATION Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 08/01/2025 Electrical Contractor OWNER CCB 000000 08/01/2025 INSPECTIONS REQUIRED II Inspections 2300 Rough Mechanical Rough Mechanical: Prior to Cover 2999 Final Mechanical Final Mechanical: When all mechanical work is complete. 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 or 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. JkO K1 — O '�-/ 7 rtes cJ �o�'t` Fr/ 2"7? kic Owner or Contractor Signature \y.N ` eOte ace`-o O0,0i Date Ose .t,_,30 r eN' e ' Oa oP\ 'fro 0\N0 0\\� ep� ao� ".»si>;, �v.<J\e5G t\ n O\\-\t ope`reti�cs.\ a ; ,;;: E�0�0 A goat ti•0� 1-°w`0\at(\�\0 .0 al• ��� (t'' ESN f�o't\PPg13,4:0°0* `ettego o'32'23 Q\�Q���O�p� e • P,N , ��S (.4� o cp. e t m b e Q04 r S1,E01/ t \��QE0 y . \S\ Ny Qt GN 1SS�P Springfield Building Permit 9/19/2013 10:12:01AM Page 1 of 1 • • SPRINGFIELD CITY OF SPRINGFIELD :tit .h.... 225 Fifth St :`��, TRANSACTION RECEIPT Springteld,OR97477 OREGON 541-726-3753 811-S P R2013-02079 www.springfield-or.gov 2991 YOLANDA AVE permitcenter©springtield-ocgov RECEIPT NO: 2013002074 RECORD NO:811-SPR2013-02079 DATE:09/19/2013 iOES.CRIPJION ACCOUNT_CODE/TRANSCODE_ ' AMOUNT DUE L1 First Appliance Fee 224-00000-425604 1006 80.00 State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 9.60 Technology fee(5%of permit total) 100-00000-425605 2099 4.00 TOTAL DUE: 93.60 LPAYMENT TYPE . PAYOR. 'CASHIER:DBOWLSBY - COMMENTS - - '. . AMOUNT PAID __._ J Credit Card . LEWIS RICHARD 93.60 015259 TOTAL PAID: 93.60 • • SPRINGFIELD- 225 Fifth St +A CITY OF SPRINGFIELD Springfield,OR 97477 ::`C Phone: 541-726-3753 OREGON Building / Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR2013-02078 www.springfield-or.gov permitcenter @springfield-or.gov PROJECT STATUS: Issued ISSUED: 09/19/2013 EXPIRES: 03/18/2014 STATUS DATE: 09/19/2013 APPLIED: 09/16/2013 SITE ADDRESS: 2991 YOLANDA AVE,Springfield,OR 97477 SCOPE: Electrical Only ASSESOR'S PARCEL NO: 1702193300804 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: EL-Garage/Shop with bedroom/bathroom above OWNER: LEWIS RICHARD A&LARSON-LEWIS LAURIE L Phone Number: ADDRESS: 81840 LOST CREEK RD DEXTER OR 97431 CONTRACTOR INFORMATION Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone . General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 08/01/2025 Electrical Contractor OWNER CCB 000000 08/01/2025 INSPECTIONS REQUIRED Inspections 4225 Service or Feeder 4500 Rough Electrical Rough Electric: Prior to Cover 4999 Final Electrical Final Electric: When all electrical work is complete. 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 or 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. YO A. �_�i tCe- ecg3 e" O" 9-/97,� Owner or Contractor ignature,DM c es 2'‘ S.95 J\es`o Date '�'•V .- �'' g s ',.='' ��ON•aao9tfroto\0 o - c\\o(on �� • to0otoat� _..00 oe\a Ac .„ek.13Na1• Q�� �Q� Fp0 NI.,0?'-yoJ�eGe” ote9o03322 �P�����O��F�. X0090 \\•k-v-0 e<kot``e s�.e �Qec\G���1\ uN�� PgP P Springfield Building Permit 9/19/2013 10:09:53AM Page 1 of 1 SPRINGFIELD - 1 CITY OF SPRINGFIELD '+' A.. 225 Fifth St :Sat TRANSACTION RECEIPT 225FithSt 97477 541-726-3753 811-SPR2013-02078 www.springfield-or.gov 2991 YOLANDA AVE permitcenter@spdngfleld-or.gov RECEIPT NO: 2013002076 RECORD NO: 811-SPR2013-02078 DATE:09/19/2013 [DESCRIPTION - • ACCOUNT CODEITRANS CODE' -. ' . AMOUNT Branch circuits with service or feeder each circuit 224-00000-426102 1004 13.00 Services 200 amps or less 224-00000-426102 1004 89.00 State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 12.24 Technology fee(5%of permit total) 100-00000-425605 2099 5.10 TOTAL DUE: 119.34 `,AMOUNT PAID i.. PAYMENTTYPE- -_PAYOR__cnsRiER_oeowLSSr -,,-_,.._ COMMENTS - „ _„ . . .,_:) Credit Card LEWIS RICHARD 119.34 • 015259 TOTAL PAID: 119.34 • SPRINGFIELD 225 Fifth St CITY OF SPRINGFIELD Springfeld,OR 97477 �( �'' Phone: 541-726-3753 OREGON Building I Residential Permit Inspection Phone: 541-726-3769 Fax: 541-726-3676 PERMIT NO: 811-SPR2013-02080 www.springfield-or.gov permitcenter @springfield-or.gov PROJECT STATUS: Issued ISSUED: 09/19/2013 EXPIRES: 03/18/2014 STATUS DATE: 09/19/2013 APPLIED: 09/16/2013 • SITE ADDRESS: 2991 YOLANDA AVE,Springfield,OR 97477 SCOPE: Plumbing Only ASSESOR'S PARCEL NO: 1702193300804 TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: PL-Garage/Shop with bedroom/bathroom above OWNER: LEWIS RICHARD A&LARSON-LEWIS LAURIE L Phone Number: ADDRESS: 81840 LOST CREEK RD DEXTER OR 97431 CONTRACTOR INFORMATION Contractor Type Contractor Name Lie Type Lic No Lic Exp Phone General Contractor OWNER CCB 000000 08/01/2025 Plumbing Contractor OWNER CCB 000000 08/01/2025 Mechanical Contractor OWNER CCB 000000 08/01/2025 Electrical Contractor OWNER CCB 000000 08/01/2025 INSPECTIONS REQUIRED 1 Inspections 3150 Underslab Plumbing Underslab Plumbing: Prior to filling the trench and including required testing. 3200 Sanitary Sewer Sanitary Sewer Line: Prior to filling trench and including required testing. 3315 Water Line 3400 Storm Sewer Storm Sewer Line: Prior to filling trench. 3500 Rough Plumbing Rough Plumbing: Prior to cover and including required testing. 3999 Final Plumbing Final Plumbing: When all plumbing work is complete. 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 Lakvf the State or Oregon pertaining to the work described herein, and that NO OCCUPANCY will be made of any struc\ure,tUithqut*rmission of the Community Services Division, Budding Safety. I further certify that only contractors and employee flo krgtyl\ mpliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspect onst P&rpoest dcsaie proper time,that each address is readable from the street,that the permit card is loc d®I�ft �ott \�rpert� d�1Ji®`�pproved set of plans will remain on the site at all times during constrP C".,nAeS doer ,o�to�0e Vol\`\e?' IA NS° . \ ooPo,\he vo�ti\o 2.--/2 ,. � O yelt, Owner dSo [a��r\�igrVaeft g�ceglp-332 Lv Date c_ (G�t �0 o ca\\t�9 tp1 kV\ .\5\-a P�� �,�c,0��1k0 c\∎10) Gee\et eV. A#9 0P� GOp`s`1 ,\9P P Springfield Building Permit 9/19/2013 10:07:47AM r�` Page 1 of 1 • SPRINGFIELD CITY OF SPRINGFIELD .C�6•02.4,�. 225 Fifth St OREGON TRANSACTION RECEIPT Springfield,OR 97477 541-726-3753 811-SPR2013-02080 www.springfield-or.gov 2991 YOLANDA AVE permitcenter©springtield-or.gov RECEIPT NO: 2013002075 RECORD NO:811-SPR2013.02080 DATE:09/19/2013 tDESCRIPTION JACCOUNT_CODE/TRANS CODE'- . AMOUNT Shower/Shower pan 224-00000-425603 1005 21.00 Sink/basin/lavatory 224-00000-425603 1005 42.00 State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 10.08 Technology fee(5%of permit total) 100-00000-425605 2099 4.20 Water closet 224-00000-425603 1005 - 21.00 TOTAL DUE: 98.28 # .PAYMENT TYPE • ,- -AMOUNT,PAID; ' . PAYOR --CASHIER:osOwpser COMMENTS • - �„ _ -�'_ Credit Card LEWIS RICHARD 98.28 015259 TOTAL PAID: 98.28 • • • Electrical Permit Application DEPARTMENT:USE ONLY SPNINGFIELD win. .., y1 ,,. k'CITYFDESPRINGFIELDIWOREGO -t 513 -cZv71- ''.1.=<:ir .,..m ;Za-Sxs-"?mac� ,_ Ia'�".: . -:z: .ux Permit no.: 225 Fifth Street•Springfield,OR 97477♦PH(541)726-3753♦FAX(541)726-3689 q L �j Date: l/� / /J This permit is issued under OAR 918-309-0000. Permits are nontransferable. Permits expire if work f is not started within 180 days of issuance or if work is suspended for 180 days. °-' -, ,, , CQCAL;GQVERNMENTiAPPROVAL"zW "y', :,igiA ittE,FEE,'SCHEDULE' i Zoning approval verified? ❑Yes ❑No Number.oli spec`t1on pert er ( -1 Qty 'r04--•st,�i r cot j „CATEGORY.:4,OF.',CONSTRUCT,ION >3. +fis ° "' "" ,f..,"` � Residential,per unit,service included: 7 Residential ❑ Government ❑Commercial tY; 4 OBµSITE INE-ORMATION'-AND,'L'OCATION4w j, ; 1,000 sq. ft.or less(4) $147.50 $ Each additional 500 sq.ft.or portion Job site address: 2 99/ Yo4.7. q Ai e' thereof - $ 27.50 $ City: �ri //P/c/ State: 0� ZIP:27Y 77 Limited energy(2) $ 35.00 $ Reference: Taxlot.: Each manufactured home or modular , $ 69.00 $ --;114 intlESCRIRTIONv ciF WORK-* x altr; dwelling service or feeder(2) /���,� / Services or feeders: installation, alteration,relocation b" - 200 amps or less(2) - ( $ 89.00 13? ,� `"` +t'`"{ "PRQRERTY:TQWNER ':,t? tF-r'' ,`.,0" 4 201 to 400 amps(2) $ 104.50 $ a'wix5�v�s�, . S�=i s a Name: � 401 to 600 amps(2) $174.00 $ Address: y'p/ y4/4ir.�4 4.7" 601 to 1,000 amps(2) $225.50 $ City: �{j(-,_Rp/,/ State: ©, ZIP.27f77 over 1,000 amps or volts(2) $516.00 $ Phoned'- ;�- 09'c c2 Fax: - - Reconnect only(2) $ 69.00 $ E-mail: Temporary services or feeders: installation, alteration, relocation This installation is being made on sidential or farm property 200 amps or less(2) $ 69.00 $ owned by me or a member of my immediate family. This 201 to 400 amps(2) $ 96.00 $ property is not intended for sale, exchange, lease, or rent. OAR 479.540(1)and 479.560(1) 401 to 600 amps(2) $138.50 $ Signature: jG�Jfj/l�— Over 600 amps or 1,000 volts,see services or feeders section above ?itr:d` i CONTRACTOR;: STALLATION ,4 - 3"r,;.`tti> ,1ky Branch circuits:new alteration, extension per panel Business name:..-'elk Jit/p'L_. a.Fee for branch circuits with purchase of a service or feeder fee: Address: Each branch circuit $ 6.50 $ City: State: ZIP: b.Fee for branch circuits without purchase of a service or feeder fee: Phone: - - Fax: - - First branch circuit(2) $ 60.50 $ E-mail: Each additional branch circuit 7> $ 6.50 $ / S CCB license no.: BCD license no.: Miscellaneous fees:service or feeder not included Signing supervisor's license no.: • Each pump or irrigation circle(2) $ 69.00 $ Print name of signing supervisor: Each sign or outline lighting(2) $ 69.00 $ Signature of signing supervisor: Signal circuit or alimited-energy panel, $ 80.00 $ alteration,or extension(2) Each additional inspection:(1) $80.00 $ '. ; `* ;A'P;PILICANT'USEra°, ,,, (A) Enter subtotal of above fees (Minimum Permit Fee$80.00) $ /4 2 (B)Enter 12%surcharge(.12 x[A]) $rn I (C)Technology Fee(5%of[A]) $` '-/D TOTAL fees and surcharges(A through C): $/ /7� 440-2584-1(4/01/2013/C0M) • . Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325 (2)) This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. • Please check the appropriate box: • I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. • Lt ,140A Print Print Name of Permit Applicant • Signature of PermitAppli n Date • • Permit#: 513 Zen. 207f Cp On. /� I�/, o F O • Address: 2-4,/ htie ast i -; 6 N; vrunp ,5-Att 6 117y 78'Issued by: Date: 59 This Copy for Permit Offices