HomeMy WebLinkAboutPermit Building 1986-4-28 (2)
j'lIlSPECTION LINE
726-3769
Job Address :1S$; J (Jl-u7+ Pr
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Legal Description\" \ . 'j -:-~. ~::-""'l :--'..... .'
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CITY UF SPRINGFiElD
COMBINATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
I~ater Heater
Ranqe
* ~TJON liNt
726-3753
Sq. Ftg. Hain
5:q. Ftg. Access.
Sq. Ftg. Other
New Add Alter ~ep.
-Fence Demo Change/Use
Other - -
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(ohone no. I
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Owner I ~7L12. e. Jw Pt[J'iA-lt..:1 LJ1t-..
Address ~ ;l.q S'. A v~;- Phone
6 Al.4J" REf& ~ 7tfl.~ t0b ("
ValUE of Hark: __G--
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Bui lrilnQ Pernlit Info~ Oeser .be Work{ Le..
Family nes;dence With Attached Garaoe)
S~c.
Construction lender
Address
Ul:.~ HiN H.A11
(namel
Phone
I address)
flies. no.)
Primary
Structural
Electrical
Mechanical
CONTRACTORS \name}
[J" I Sf! ~ L-LiCy
(addrp$S)
(1 ire;._ nn.)
(pxo;rpc;.) {nhonp nn, ,
to if J. - 2<:x" .L
General
Plumbino
Electrical
~1echanical
PLUflBING
\ \ \ ~
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I FFF CHARGE J10
ELECTRICAL
,
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MECHANICAL
, " \ \\
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..J!Q.,..
~FF r~ NO.
F'F F' . r'iAB!i[
Each sing1e fixture
Residence of
SQ. FT.
furnace/burner to
BTU's
Relocated building
(new fix. additional)
S.F. Residence
(] bath)
Duplex (1 bath) each
Additional bath
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
~n~rp h~~tpr ~nrl vpnt
Stonn Sewer
Of
amps.
Appliance vent
seoa ra tf'
Stationary evap.
cooler
Vent fan with
sinole duct
Vent system apart from
heatino or A.C.
Mechanical exhaust
hood ;lnd dur:t
Wood stove/heater
Water service
Temporary Construction
Change in existing
re'i;r1~nce
multifamily. camm. or
Induc;.trial
Sewer
CDMI.I./IND. FEEDERS
Install/alter/relocate
dic;.trib. fppdprc;.
Of
amps.1
ISSUANcr OF PFRtlIT
TOTAL CHARGES . TOTAL CHARGES TOTAL CHARGES
WHERE STATE L;\\~ REQUIRES that the Electrical work be done by an 'Electrical Contractor, the electrical portion of this pernit
shall not be vali1 until the label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXAMINED the completed application 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 Oregon pertaining to the work described herein, and that HO OCCUPAUCY will be made
of any structure without the permission of the Building Division. 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 comoliance with ORS 7nl.055 will be used on this project.
ImlE(please printJ,"1JHIJ P. I!1ltUl-OuJI5 Irr'-- SIGNATU~ R~ .ft-
FOr. OFFICE llSI" m~LY , 1/
Units - ~o. Ftg. rlain I x
1.4...\""
Occy Load Sq. Ft9. Access ' .' \ \ I', X
Occy Groun"\_- ... j,..' Sq. Ftg. Other
OATE_Y~ 2 f' -It, '
Zone --<__'~_' Tvoe/Const.\ I
Fire Zone -. Bedrooms
Flood Plain .-." Stories
~ '\--. \
x
Value
Value
Value
PLU!\BING PERMIT
Charges and
Surcharges
.'y_~ ;::"oJ t Plan n. COITlTl/Ind
{--' 1....' , 65%/Rlda Pp:r Fpp
-----\--;"Z.r------pran Ck. Res
. r \". I 30%/Bldo Per Fee
Fence
.w~ 0(P~'YD .
I "/ '"\ C....:>
......~.>
TOTAL VALUATION
, .
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BUILDING PERNIT
Charges anc.
Surcharges
ISystems Development I .-'. .~,
CharQe tL5~)' .-'" -:-.\
Demo
ELECTRICP.L PER'~IT
Cha rges and
Surcharges
Sidewalk
A/C Paving
Total Comb. Permit
TOTAL
I 'c-!~.6q
. . .
MECHANICAL PERMIT
Charges and
Surcharges
Curb Cut
~
.
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT V~LID~TION
I. Applicant to furnish
A. Job Address
B. legal Description
1. exa~~le~ Tax Lot 100. Lane County Map Reference
J./ UJ 4J
2. examole- Lot 1. Block 3, 2nd Addition to
~prlngtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. examDle~ heat/electrical ceiling/or forced air oas
2. examole- waterheater/electrlcal/or solar
E. Square footage or valuation, etc. ------
1. examole- 1250 sq. foot house. 500 sq. foot garage
2. examole- 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
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 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 Cl erk
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PROJECT CONDITIONS TO BE S~TISFIED BEFORE OCCUP~NCY:
'4'
Permit applicant exempt from registration with the Builder's Board because:
~dditional Project Information:
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PL~NS REVIEWED BY:
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name.',. '\- \ ')' '<-- .;-\-\ 1_.\ '"
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signature\!\ .,.. (\ ro. ';-:-~_\/ date k.\- 1...'....\-;\.'''
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