HomeMy WebLinkAboutPermit Building 1984-10-30
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fiTlSPECTION LINE CITY OF SPRINGFIELD
1726-3769 - COMBInATION APPLICATION/PERMIT
Job Address ., ~_ ~ .....4. / ../I EIIERGY..50UIJ.CE~.;,.-
'"" "" ^ . ,rA.. rr ,__.~ Heat cU::;C,
Legal Description _~_ '5';" J?1---1:::;'iS~':'~n!1 !~ater Heater-
Ranqe -
I? -"'( lA./' u/ """ LOT
Owner s:.e ,/ -+ IA " " ,; P A-t' "f Ie ,
Address
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INFORf1ATION 111'tt
726-3753
Sq. Ftq. f.lain /(. (~)
~q. ~tg. Access. ----
Sa~tg. Other -----
~ew 'Add Alter ~ep.
--Fence Oemo Change/Use
Other - -
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I? P.
Va~H("rk:\-
;;nfr7n-
I
Builaina Permit Info: Describe Work{i.e..
Familv nesidence With Attached Garaqe)
Build Single
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f'..
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00
Phone
Construction Lender A/('j) "f/~
/'FlhrtJ rJ5:Gh
n...('f-rc..C;;;
f'. fI-~
lname)
Phone
(address)
/!CJO ~
(lies. no.) (exoir~
#.
Address
Ul:.SHirl I tAr.,
,
(ohane no. J
...
Primary / .,tf-/.7J?y
Structural
4LL6/f/
/.r<t.. <:' ,'AldL fLlTl.&IkA7.=nJ>
.J"<.r'J- <./ ~L ,_
Electrical
f1echanical
CONTRACTORS
(name)
(address)
gf!:: r<?() .puv;rGItJUL~
{1 ir.",. no.
(e)::n;r~c;.)
(phone no.)
General D f"/ /J1 ~ T ui,if-'=
Plumb;na
Electrical PAt ~ _1/ c3ZC('7~Lr 15<:; A/ ./ f/"vt , "/''''~/f ,t,!;Zr.5./J/) <f-:l v -Y';
5SS0
-,=/?-y,
<Sf'7 -'2P4 /
~lechan; ca 1
PLUIIBING
"'J.~
FEE CHARGF
ELECTRICAL
MECHANICAL
(j~
IlU.
NO
FFF
f:HARr,F NO.
FFF rHARGF
SQ. FT.
furnace/burner to
BTU's
Each single fixture
Residence of
Relocated building
(new fix. additional)
S.F. Residence
[l bath)
Duplex (1 bath) each
Additional bath
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
SOnce he~tpr ~nd vpnt
Storm Sewer
Of
amps.
Appliance vent
c;eoarate
Stationary evap.
cooler
Vent fan with
sinole duct
Vent system apart from I
heatina or A.c.
Mechanical exhaust
hood <'Inct duct
Sewer
Temporary Construction
Change in existing
res; denc!'
multifamily, camm. or
Tndu..trial
\o-Jater serv; ce
COI1f1. /I NO. FEEDERS
Install/alter/relocate
d;<;.trih. fpprlerc;
Wood stove/heater
I
I
I
I
I
\
ofi ;.::'; \( l{)
amps.
I()~ IO,<A.
ISSUANC, OF PFRIIIT
TOTAL CHARGES
WHERE STATE L~W REQUIRES
shall not be valij until the
. TOTAL CHARGES
that tile Electrical work be done by an
label has been signed by an Electrical
TOTAL CHARGES
Electrical Contractor. the electrical portion of this permit
Supervisor and returned to the Building Division
I HAVE CAREFUllY EXAMINED the completed ap~lication for permit. and do hereby certify that all information hereon is true
and correct, and I further certify that any and all work oerformed shall be done in accordance with the Ordinances of the City
of Springfield and the laws of the State of OrelJon pertaining to the work described herein. and that tiC OCCUPAr~cY will be made
of any structure without the permission of the Building Oivision. I further certify that my registration with the Builder's
Board is in full force and effect as required by ORS 701.055, that if exempt the basis for exemption is noted hereon, and that
only subcontractors and employees who are in cornoliance with OP.S 7nl.055 will be used on this project.
NAME(pIease print)
DI'1-I11
t11 qu IV~.F
SIGUATURE4 7JJz.~
FO~ OFFICE USE DULY ." /.~
Units \ So. Ftg. Ilain 'rC'~,-" ';
Occy Load_ Sq. Ftg. Access
Occy Group~-'~ Sq. Ftg. Other
...
IJ4f \3 c;, S1~ Z.
Comn/lnd 1.11
por Foe If' /3.0{)
Res I
Per Fee
I
DA TEl tJ - ,5U - ~<I
Zone (_ t~
Fire Zone -
Flood Plain _
Tyoe/Const~ \..)
. -
, ~()
...-1-
LLL
Bedrooms
Stories
x
Value \."
Value
Value
\
x
TOTAL VALUATION
BUILDING PERMIT
Charges and
Surcharges
I ~/"'_ _ I Plan Ck.
__'..!~________ 65%/Bldo
\ q 1.\ Plan Ck.
, 30%lBl do
\" \'.
N\~
------------
IO~~o,-f<.{
syste. r:1S Development I
rP~Q Charoe (1.5~)
C\O.M
. .,
DeRlO
\ C~"\ )~FIl ~ ~V
?'":l., '-lC>_ \~ cD
~_. :).
\0.'-\0
PLU'1BING PERMIT
Charges and
Surcharges
Fence
ELECTRICAL PERf:IT
Charges and
SiJ.r~harges
\(), . -' Sidewalk
-----~~\U-- A/C Paving
_..-:_\.;ll...~____ Curb Cut
Total Comb. Permit
"ECHANICAL PERMIT
Charges and
Surcharges
I
I TOTAL ,\ l\C6:V4___
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Applicant to furnish
A. Job Address
B. Legal Description
1. example- Tax lot 100. Lane County Map Reference
II 03 43
2. example- Lot 1. Block 3, 2nd Addition to
~prlngt;eld Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. exam~le- heat/electrical ceilin~/or forced air Qas
2. exa~le- waterheater/electrlcal/or solar
E. Square footage or valuation, etc. -----
1. examole- 1250 sq. foot house. 500 sq. foot garage
2. examplea 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. examole - remodel existing garage into family room
3. examole - convert single family residence into
restaurant (change of use)
G. Value of work as defined in Section 303 (a) of the
Structural Specialty Code
H. DESIGN TEAM AND CONTRACTORS
To avoid design or construction delays, Building
Oivision 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 abbreviated schedules you should consult the
full schedules
C. BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
D. As noted on the CAP, the label must be delivered to the
electrical contractor for signature by his electrical
supervisor. The general contractor is .not authorized
to sign the electrical label. ---
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 type written 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.
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V. FOR OFFICE USE ONLY
Permit Clerk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPAnCY:
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Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
nam-;QN._)\~\:.: \ p., \\ signaturelJrl-o. _A:V~_\r-
date \ \ -'2.- \.\- ~q
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