HomeMy WebLinkAboutPermit Building 1983-11-9
I INSPECTION LINE
726-3769
Job Address ~ ~ '2'2..
CITY OF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
(' . 0 <:1 ENERGY SOURCES:
-O~j(l'A.O ~ Heat
('later Heater
Range
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Owner' Pt'i..~L t' J (Y\ r~.MJ:'\u')V)Ci S ' ,
Add ' ~ - I Ph ,I ~,-., "BuildinQ Permit Info: Descr,be Work( Le.,
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INFORl1ATION llN~
726-3753
Sq. Ftg. r'lain
:q. Ftg. Access.
Sq. Ftg. Other
New Add Alter Rep.
--Fence Demo Change/Use
--Other -- --
Build Single
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Legal Description
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Address
DES I GN TEAI4
(name)
Phone
(address)
(lics. no.)
(expires)
(phone no. )
Primary
Structural
Electrical
Mechanical
CONTRACTORS
Plumbinq
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(address)
!lics, no.)
(expires)
(phone no. )
Genera 1
Electrical
~lechani ca 1
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PLUtlBI NG
ELECTRICAL
MECHANICAL
NO.
FEE CHARGE NO~
I ~~~ I rHAR(.;~1 NO_ I
SQ. FT.
furnace/burner to
BTU's
I ~~~ I rHAR(';~ ~~
Each single fixture
Residence of
...
..
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
(l bath)
Duplex (1 bath) each
Additional bath
I ~Ja ter serv ice
I Sewer
IStorm Sewer
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SERVICES
Recessed wall
Soace henter nnd vent
Temporary Construction
Change in existing
residenc('
Imultifamily, comm. or
Industrial
10f amps.
ICOMM./IND. FEEDERS
I Install/alter/relocate
distrib, feeder~
10f amp~
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Appliance vent
seoarat~
Stationary evap.
cooler
Vent fan with
sinole duct
Vent system apart from
heating or A.C.
Mechanical exhaust
hood and duct
Wood stove/heater
TOTAL CHARGES TOTAL CHARGES
WHERE STATE L'\l~ REQUIRES that the Electrical work be done by an
shall not be valiJ until the label has been signed by an Electrical
ISSUANCE OF PFRr1IT
TOTAL CHARGES
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:EI~ct~ical'Contractor, the~lectrical portion of this permit
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 performed 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 NO OCCUPArKY 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 compliance with ORS 701.055 will be used on this project.
IW1E(please print)X n./? W/? //,dgA/ SIGNATURE 1(.,~
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FOR OFFICE USE ONLY
Zone Type/Cons t. Units Sq. Ftg. 11ain
Fire Zone Bedrooms Occy Load Sq. Ftg. Access
Flood Plain Stori es Occy Group Sq. Ftg. Other
DATEI '/w, 9-93
x
Value
Value
Value
x
x
TOTAL VALUATION
BUILDING PWlIT 'PI an Ck. Comm/Ind
Charges and ------------ 65%/Bldo Per Fee
Surcharges Plan Ck. Res
30%/BldQ Per Fee
PLUMBING PERMIT, ----.2(1. .00 Fence
Charges and
Surcha rges .80 D~mo'
ELECTRICAL PERrm ____1QJJO I'Sidewal k
Cha rges and
Surcharges .1./0 I A/C Paving
I1ECHANICAL PERMIT I Curb Cut I
Charges and
------------ IU~~1
Surcharges
,
Systems Development
Charge t1.5K) ",
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-bstJ n - f<.
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Tota I Comb. Permit ,:',\
, ro I TO:AL $ 5lo.40 I
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
IV.
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 Adpition to
Springfield Estates
C. Name, etc. 'of owrier and constructi on 1 ender
D. , Energy Sources '
1. examDle- heat/electrical ceiling/or forced air qas
2. example- waterheater/electrical/or solar
E. Square footage or valuation, etc.
1. exa~ple- 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 (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, thel'iibel must be del ivered to the
electrical contractor for signature by his electrical'
supervisor. The general contractor is ,not authorized
to sign the electrical label. -
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.
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 SATISFIED BEFORE OCCUPANCY:
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Permit applicant exempt from registration with the Builder'~Board becau~e~'
Additional Project Information:
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PLANS REVIEWED BY:
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name
signature
date
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