HomeMy WebLinkAboutPermit Building 1982-3-24
CONSTRUcerON/PLACEMENT
PERM IT ICj ~~~;~~a~io~ID_8V
/J3-
C/, 0 Two Copies of Plans
Cm1PLETE THIS BLOCK. PLEASE USE BLACK INK AND PRINT. 0 Two Copies of Plot Plans
TOWNSHIP J RANGE I SECTION 4-- J TAX LOT DOUT OF DMechanical Checklist
17 03 23. . 't' Ire DPlurnbing Checklist
SUB.I!P#f_ ON:::;'A:lT:I'O~ "fP~t'll """.J..J P..J..., I UJT/IP~CEL I BLOCSK
~~ [1L)1Jl ,LJ J,\cnrtf1 ~~ ~ Dplan Check Info Sheet
L~O~ADIDRESS l ., STREE,,::, .;)~. ~ ~A., ~A"';';;::; ZIP PR()p~USE OF PROPERTY
~~ ~~ C)~~ . ~ ILf I I GarRes~dent~al [Jrndustrial
S'r~~~LY 0 ~ I will.. ~ n";;' '\ 0 Commercial OPublic
D~r~R07(~~ 0( ddd {c W(J~h~ ~X I S VALUE
3~Db2:4 r · OF Z~ I # OF Cl(- I ~~oo:J L/ ~~~~~~~
~ Q1;0G, )ei5>{mQ/'r--J : bl49-l n~o:z) ~ . ~7:N79cf~
~cts NAME'AND Aoil@-U~)' 2P5j~ Oc: CrfLtt7 IrELEPWONE\"UAeER
CONT:~ rrTIONS ro SITE , L:?j. , a.i~ '- ~ ~
~~~,~~-a:~::::"~ ,:'"!~. ,,~;9:, ,., ,""",,
certify that any and all work performed shall be done in accordance with the Ordinances of Lane County and the Laws of the SUite of Ore'l,)fl pertaining
to the work described herein, and that NO OCCUPANCY will be made of any structure without the permission of the Building Division. I further certify
that regintration 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 not!.'d
hereon, nnd that only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project. I HAVE READ AND CHECKED THIS
APPLICATION THOROUGHLY.
..
.
FOR OFFICE USE ONLY
'I.. ~~}I'r:=.( 2. WE (b>>vJH1
NAME (please print)
+&JLT~~--
~ler
IC} 111/'J.1Z.-Jz- 0 Contractor
- DATE o Agent
o PLANNING/ZONING:
Zone R A
C A=/
Minimum Setbacks: L, front I:. J
commentg,~J~^ +n..d.~ ",.('1 J.Jor J.. OA. T
Parti tion ;r
Parcel it
interior 5/
~~ck<'J
Parcel sizeC]5.c5 XC:q:f25
rear '~"/PUc, ,
CL, side
In flood hazard area?
,
rn:o
Date:
~-1q~~
~
n
D
o FLOODPLAIN:
o EURAL ADDRESSING:
0"SANITATION:
[] Ves, see attached sheet.
Date:
GRiD COORDINAtE
N
E
Date:
S. 1. #
B. P.
# 8:J7-7n
Installation
Specifications:
Installation Record Issued? QSlves [] No
~i'vtl.", Gallon -e.xV;fi'VlG\ Lineal Feet
I~..J Tank If?) ~ of Drainfield
tfi;u ~"'" 0 (Ju)
- CfrI"
Maximum Depth
of Trenches
Type
Y),
~I\.)
d.ttp~e/ ~(/~>7/l)O,
, . :v., ~1r:c? 'lnLcf1u) -P J'.A~/1/
hDate,J9.mao ~~ a ~l.tJ
Use ~ ~ij~
PLANS EXAMINATION:
Group_'f? ::::>
Comments:
Date:
g....-M.,..-~7~
lWv
CONSTRUCTION AUTHORIZED BY THIS PERMIT
D~scri.ption
Odc1U1er0
Sq, Ft.
c-m
Fixed Fee/
Unit Cost
Floodplain
Subsurface
Fee
Fees
$'
$
$ -.J~p;(')
$
$ 1':5.00
$ , Hi'OO
$ 1o"LI,~
$ ~.€:6 _
Z&5.~
4770
Building Fee
Sewer/Storm Drain/Water
_~ Plumbing Fixtures
Mechanical
P laos Check Fee
State Surcharge
TOTAL VALUATION
$
TOTAL PEE $
FEES PAID BY, ~eck 0 Cash
BY'~
Date: .3.10/:>17.1
~~--f!v
M~u~ '\
PERMIT APPROVED BY BUILDING OFFICIAL/DESIGNEE (per ORS 4S6.stS(l))
CDUNTY DEPARTMENT OF ENVIRONMENTAL MANAGEMENT / 125
DATE
LANE
C74-194
SEE REVERSE
EAST EIGHTH AVEN\E. EUGENE, OREGON
97401
.
.
~'-..
SETBACKS AND OTHER CONDITIONS Of APPROVAL MUST BE STRICTLY OBSERVED, VIOLATION CAN RESULT IN REVOCATION OF THIS PERMIT,
CITATION UNDER PROVISIONS OF LANE COUNTY'S INFRACTION ORDINANCE, AND/OR OTHER REMEDIES ALLOWED BY LAW,
WHEN READY FOR INSPECTION CALL 687-4065, A MINIMUM OF AT LEAST 24 HOUR ADVANCE NOTICE FOR INSPECTION REQUEST MUST BE
GIVEN. Have the following information ready: Permit number, job address, type of inspection, when it will be ready,
your name and phone number, and any special directions to site.
BUILDING DIVISION:
REOUIRED 1I1SPECTIONS
1) FOUNDATION INSPECTION: To be made after trenches are excavated and forms erected and when all materials for the foundation
are delivered on the job. Where concrete from a central mixing plant (colTJllonly termed IItransit mixed") is to be used,
materials need not be on the job.
2) CONCRETE SLAB OR UNDER-FLOOR INSPECTION: To be made after all in-slab or under-floor building service equipment,
conduit, piping accessories and other anCillary equipment items are in place but before any concrete is poured
or floor sheathing installed, including the subfloor.
3) FRAMING & INSULATION INSPECTIONS: To be made after the roof, all framing, fire blocking and bracing are in place and
all pipes, fireplaces and chimneys and vents are complete and all rough electrical and plumbing are approved, All
wall insulation and vapor barrier are in place.
4) LATH AND/OR GYPSUM BOARD INSPECTION: To be made after all lathing and gypsum board, interior and exterior, is in place
but before any plastering is applied or before gypsum board joints and fasteners are taped and finished,
5) FINAL INSPECTION: To be made after th~ building is complete an~ before occupancy.
APPROVAL REQUIRED, No work shall be done on any part of the building or structure beyond the point indicated in each
successive inspection without first obtaining the appr~val of the building official, Such approval shall be given only
after an inspection shall have been made of each successive step in the construction as indicated by each of the inspections
required.
NOTE: All building permits require inspections for the work authorized, such as but not limited to:
A, BLOCK WALL: To be made after reinforCing is in place, but before any grout is poured. This inspection is
required for each bond beam pour. There will be no approval until the plumbing and electrical inspections
have been made and approved,
B. WOOD STOVE: To be made after completion of masonrv (if applicable) and when installation is comolete.
Installation shall be in accordance with an approved nationally recognized testlng agency and the manu-
facturer's installation instructions.
C, MOBILE HOME: An inspection is required after the mobile home is connected to an approved sewer or septic
system for: setback requirements, blocking, footing connection, tiedowns, skirting, and plumbing
connections.
(1) Footings and piers to comply with State foundation requirements for mobile homes or as recommended
by the manufacturer.
(2) Mobile home minimum finish floor eleyation shall be certified when required by a floodplain
management letter,
(3) Mobile home tiedowns, when required, and skirting shall be installed and ready for' inspection
within at least 30 days after occupancy. Tiedowns and skirting shall be installed per enclosure.
D. SWIMMING POOL: Below grade when steel is in place and before concrete is poured. Above grade when pool
is installed.
APPROVED PLANS MUST BE ON THE JOB SITE AT ALL TIMES DURING WORKING HOURS. THIS PERMIT WILL EXPIRE IF WORK DOES NOT BEGIN
WITHIN 180 DAYS, OR IF WORK IS SUSPENDED OR ABANDONED FOR MORE THAN 180 DAYS. SUSPENSION OR REVOCATION MAY OCCUR IF THIS
PERMIT WAS ISSUED ON THE BASIS OF INCOrlPLETE OR ERRONEOUS INFORMATION.
ANYONE PROCEEDING PAST THE POINT OF REQUIRED INSPECTIONS WILL DO SO AT HIS OWN RISK
SUBSURFACE AND ALTERNATIVE SEWAGE DISPOSAL SYSTEMS
(1)
(2)
Permits shall be effective for one year from the date of issuance.
Upon completing the const~uction for which a permit has been issued the permit holder shall notify. the
Department by submitting the installation record form. The Department shall lnspect the constructlon ~o
determine if it complies with the rules contained in this division. If the construction does comply ~Ilth
such rules, the Department shall issue a certificate of satisfactory completion, to the permit holder. If the
construction does not comply with such rules, the Department shall notify the permit holder and s~a11 requlre
satisfactory completion before issuing the certificate. Failure to meet the requirements fo~ sat,sfactory
completion within a reasonable time constitutes a violation of ORS 454.605 to 454,745 and thlS rule.
SetS~cks - Subsurface SewaQe Disposal
From: Interior property lines
Edge of road right-of-way
Building foundation
Wells. other water sources
SeDtic Tank
10'
10'
5'
SO'
Drainfield
10'
10'
10'
100'
. .
I. 1
.'
lane county
ca
. .
CH ECKLIST
PLUMBING/ MECHANICAL
APPLICANf INFORMATION:
U)Q.lo..vYlOIYL.. \~
(Name oUmn-Pleas'e ~nt) , (Malllllg AddreSs)
PLUMBING CONI'RAcrOR
o Yes Finn
Address
o No o Self
MEGlANICAL CONI'RACTOR 0 Yes Finn
Address
o NoD Self
Type of Fixture
pLJMBING
Number of Each
Total
Sink
Lavato!" (Wash. Basin)
Tub (with or without shower)
Shower, separate
Water Closet (toilet/urinal)
Dishwasher
Disposer (garbage grinder)
Washing Machine
Water Heater
Floor Drain
Sewer--lst 50ft.
each additional 100 ft.
Water Service--lst 100 ft.
each additional 100 ft.
Stann and Rain Drain--lst 100 ft.
each additional 100 ft.
Special Waste Connection
Sewage and Sumo Pump feiector)
M:lbiie Home Sewer and Water
Other (specify)
SUB- TOTAL (Minimwn $10.00)
J
I
i
J TOTAL FEE
Type of Equipment
MEGlAN I CAL
Number of Each
Mechanical Pennit Base Fee
Furnace UP to 100,000 BTU/H
Furnace over 100.000 BTU/H
Clothes Dryer Vent
Bathroom Ventilation Fan & Duct
Ran~e Hood with Mechanical Exhaust
Wood Stove
Air Conditioner Only
Heat Pump
Floor Furnace
Gas Piping System 1 to 4 Outlets
Per Outlet
Other (specify)
SUB-TOTAL
IroTAL FEE
OFFICIAL USE ONLY
ApplL/
Penni t #
(cny or Town) (Zlp Code)
Cant. OSR#
Cant. OSR#
Fee On Each
$ 5.00
5.00
5.00
5.00
5,00
5.00
5.00
5,00
5.00
~., 00
15.00
10.00
15,00
10.00
15.00
10,00
5.00
5.00
10.00
Fee on Each Total
$ 10,00
$ 6.00
7.50
3,00
3.00
4.50
6.00
6,0'0
6.00
6,00
.50
.'
."
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.
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.
.
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.BP
BP
BP
.BP
BP
BP
PL
· MECH
SUR
.PCI<
, 1
.
LC 48~>82 RAM
NO. FIXTUI~ES:
. CATG: APP
SEQU: 0
TAKEN BY CAD
RA
.
..
.
\ '
3
NO.
FP
600
CONNECTORS:
MECHANICAL FEE
STATE SURCHARGE
PLAN CHECK FEE
SDS
SI
PCK
1
040582
EST. COMPLETION DATE
.
.
.
.
.
I I
.
.
.
.
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.
.
.
47.70
28620
. LANE COUNTY DEPT ENY MGT F~ECEIPT ~ 48582 DATE
APPLICANT WEIGMAN, DANIEL AD DR 2421 DUMAS DR., SPFD., OREGON
TLI 1703234400108 SUBDIY NORTHWOOD ESTATES LOT 16 BLK 5
. NEW BLDG TYPE USE R BDRMS 0 UNITS 001 STORIES 2 ~BLDGS 001 PHONE 747 779iia
CODE APPL NO ACTION DESCRIPTION SQ FT UNIT COST VALUATION . FEE DAY~
" ~P ADD TO
DWELLING
" 28620
1 5 .00 EACH ,=
4%
65%
OTH
ISS
2
TOTAl. FEE**
188.50
15.00
13.00
8.66
140.73
"-
365.89
.
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0319.'
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TRS. TT
Plat
Plan
Subdivision 3.JA""~..'.. '1"., kl^.-J."~J 1"5t.
Lot
C74-150
)( f'
Block 06
Vicinity Map
Job Location
Permit fJ
Permit fJ
Permit fJ
(Address)
For
For
. For
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Permit fJ
Permit fJ
Permit fJ
Of 5C;5'
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For
For
For
30'
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f;- 10'-;'
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PLEASE USE BLACK INK AND PRINT.
I AANGE (5 :3 I SECg~ . <4. 4- TfOb
SUBD:r,Vl~ION,/PART:IION (if appl-iCable) ,^_~~l .tC.s..1 LOT/PA,.RCEL I BLOCK
:.:jr. delo ~f() N.Or+I1l.J.Jux.LU>~ lid 5
L,91~rRESS 1.Y\u-;a 3 ~. 'SP?d, o.?4rl7
sT~g~S,"::~;etLY)!:1(i~_LLA. ~u.>e1t; n X 'I 0 Commercial Dpublic
D~SCRIPTI~)lF PR~~DSED 'WORK X..J "r"~ Il.v" I L V ...-l , , . ~ LI . A_ I ' VALUE
L~{I.N'I)o(J Jl D!'--!>\ Ci'du "fU oIVl'-''Dn n'x G\...U.J'C. -\..VT1 ><
.. OF BEDROOMS ...A. I" OF STORIES I # OF ~LOYEES I wJtrJ:rn. SUPPLY l.'"'- -.. "\ V
:340 ~.., L........ v...J r<tiJlY'ltdeJl..U
'lE\i:;:;I;D"G )eJ'?\n1CW->: gl-1g.j "~'Z5 ~.
CONTRAr:~~N~;;DD(J2;'~6b()~)' ~>O~ Ote.<s< ~mv 1
CONT:~Qf OSR' I Ha7~~ -ftd s? '-1<d'. l a-*~-Osf- ~..hGeL t~
NOI H1 6)') -~LL'Y'no.'1) . 'CQrdho'/J'f,P, VO{.A.>I ~~..'
, . '
I'IlAVE CAREFULLY EXAMIN~E COMPLETED APPLICAT~R PERJolIT, and do hereby r:ertify that illl information hereon i~ true and correct and I further
certify that any and all work performed shall be done in accordance with the Ordinances of Lane County and the Laws of the SUite of Oreqoll pertaining
to the work described herein, and that NO OCCUPANCY will be made of any structure without the permission of the Building Division. I further certify
that, 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. I HAVE READ AND CHECKED THIS
APPLICATION THOROUGHLY.
CONSTRU~ION/PLACEMENT
PERM.IT
.
FOR OFFICE USE ONLY
TOWNSHIP
17
DOUT OF
APPl~ca~ionA~'5 ~O?
Permlt # ~ l) -~
o Two Copies of Plans
[]TWO Copies of Plot Plans
[]Mechanical Checklist
[JPlumbing Checklist
[JPlan Check Info Sheet
COMPLETE THIS BLOCK.
ZIP
PROPOS~D USE OF PROPERTY
~esidential [JIndustrial
D,proposed
o Existing
TELEPHONE NUMBER
~ 7- 7-rq =<,
'TELEPHONEINu~mER
'i-. ~d}l'f ( 2,/AIF U..rJo\AU,
NAME (please .print) -
n . ()y ~
tJY c.-:-r f:oN~!10-
J...911m tl. ,}- ~
DAgen t
B~Owner
[J Contractor
DATE
o PLANNING/ZONING: Zone RA
C ' Ahtl
Ninimum Setbacks: L, front~
Comments: V'.')" ~^ ~ A ~
Parti tion 11
Parcel #
~)I
interior (..
,i.\.O...;f'ht.;; cl~A-
Parcel Siz~t).a:. )( a ,;,1.1
1"--- -
rear IF> ~L1 G ,
eL, side
, ('./ .t.h }'.i.A' t
o FLOODPLAIN:
o RURAL ADDRESSING:
,
E:1 SANITATION:
In flood hazard area?
..-
~NO [] Yes, see attached sheet.
Date:
.2., -(:/ ~ 'X' -2
r-:r
'~~"1'
n
o
Date:
GRID COORDINATE
N E
Date:
Installation
Specifications:
S. 1. /10
I'y.wl.-" ,
IfYI'n- )
B. P.
. ~'Y."}7"':ln
Installation Record ISSUed?[;lYeS [] No
Gallon
Tank
.
l?A\<-.f1vf) ~ Lineal Feet
l'~ \ of Drainficld
Maximum Depth
of Trenches
y
Comments: ,1JD,"},"'((lt(J
" J
t .r/J I JI;/ ,:11.:",
~. . If /_. I, I
,~1 . j If.! t J. / I..: .".... I; ,
~PLANS EXAMINATION:
II
'..'L. :.......1...(' ...1 l/tltJ /
:' ,.J,
I,. mu_~_
/..'7.. 7{).
Type ::71,)
I.'/f...,!
,
. I'
... (.
jo
....
,
1
'I f, / ','
ict ,linn ;;2J
,
,
l'. /,.1,
:':. ../;;;,,,,.
lv: ; ..J~;, (J.J u:I~Jt)1.(d
I
,If.
j
I, / I, ./J ~
"'-1 .
II
Group
12 ;2,
Use :=:;:: I
/ Date,
)/,\ .
I
r'
j
~ [1ill~
Comments:
Date:
::?....- '::'4" 0".
[7;} /
CONSTRUCTION AUTHORIZED BY THIS PERMIT
Description
r"'l Jd"
l ,e. .l 11r:nv
Sq, Ft.
, Coi:D
Fixed Fee/
Unit Cost
Floodplain Fee
Subsurface Fees
Building Fee
Sewer/Storm Drain/Water
~-==') Plumbing Fixtures
Mechanical
Plans Check Fee
State Surcharge
$
$
$ I~A.c=jn
$
$
$
$
$
15.m
1:0.00
~,~
~ ,f=:6
.et6 .ef1
47m
TOTAL VALUATION
$
$
..-
FEES PAID BY: 0 Check 0 Cash
By: ('nffCl!
Date: ..3. "}I.5i?.1
r;:?; ....-q~ r./C'
,;.... l/
TOTAL FEE
tvl"'~Ii'..0fh "
PERMIT APPROVED BY BUILDIN~ OFFICIAL/DESIGNEE (per ORS 456.b05{1))
LANE COUNTY DEPARTMENT OF ENVIRONMENTAL MANAGEMENT / 125 EAST
DATE
EIGHTH AVENUE, EUGENE, OREGON
97401
C74-194
SEE REVERSE
.
.
,
....,.
.
SETBACKS AND OTHER CONDITIONS OF APPROVAL MUST BE STRICTLY OBSERVED. VIOLATION CAN RESULT IN REVOCATION OF THIS PERMIT,
CITATION UNDER PROVISIONS OF lANE COUNTY'S INFRACTION ORDINANCE, AND/OR OTHER REMEDIES ALLOWED BY LAW,
WHEN READY FOR INSPECTION CALL 687-4065. A MINIMUM OF AT LEAST 24 HOUR ADVANCE NOTICE FOR INSPECTION REQUEST MUST BE
GIVEN, Have the following information ready: Permit number. jOb address. type of inspection, when it will be ready,
your name and phone number, and any special directions to site.
BUILDING DIVISION:
REOUIRED IIlSPECTIONS
1) FOUNDATION INSPECTION: To be made after trenches are excavated and forms erected and when all materials for the foundation
are delivered on the job. Where concrete from a central mixing plant (corrmonly termed Iltransit mixedll) ;s to be used,
materials need not be on the job,
2) CONCRETE SLAB OR UNDER-FLOOR INSPECTION: To be made after all in-slab or under-floor building service equipment,
conduit, piping accessories and other ancillary equipment items are in place but before any concrete is' poured
or floor sheathing installed, including the subfloor.
3) FRAMING & INSULATION INSPECTIONS: To be made after the roof, all framing, fire blocking and bracing are in place and
all pipes. fireplaces and chimneys and vents are complete and all rough electrical and plumbing are approved, All
wall insulation and vapor barrier are 1n place.
4) LATH AND/OR GYPSUM BOARD INSPECTION: To be made after all lathing and gypsum board, interior and exterior, is in place
but before any plastering is applied or before gypsum board joints and fasteners are taped and finished.
5) FINAL INSPECTION: To be made after the building is complete and before occupancy.
APPROVAL REQUIRED. No work shall be done on any part of the building or structure beyond the point indicated in each
successive inspection without first obtaining the approval of the building official. Such approval shall be given only
after an inspection shall have been made of each successive step in the construction as indicated by each of the inspections
required.
NOTE: All building permits require inspections for the work authorized, such as but not limited to:
A. BLOCK WALL: To be made after reinforcing is in place, but before any grout is poured, This inspection is
required for each bond beam pour. There will be no approval until the plumbing and electrical inspections
have been made and approved,
B, WOOD STOVE: To be made after completion of ma<onrv (if applicable) and when installation, is comolete,
Installation sha 11 be in accordance with an approved nationally recognized testlng agency a"d the manu-
facturer's installation instructions.
C. MOBILE HOME: An inspection is required after the mobile home is connected to an approved sewer or septic
system for: setback requirements, blocking, footing connection, tiedowns, skirting, and plumbing
connections.
(1) Footings and piers to comply with State foundation requirements for mobile homes or as recommended
by the manufacturer.
(2) Mobile home minimum finish floor elevation shall be certified when required by a floodplain
management letter.
(3) Mobile home tiedowns, when required, and skirting shall be installed and ready for inspection
within at least 30 days after occupancy, Tiedowns and skirting shall be installed per enclosure.
D. SWIMMING POOL: Below grade when steel is in place and before concrete ;s poured. Above grade when pool
is installed.
APPROVED PLANS MUST 8E ON THE JOB SITE AT ALL TIMES DURING WORKING HOURS. THIS PERMIT WILL EXPIRE IF WORK DOES NOT BEGIN
WITHIN 180 DAYS, OR IF WORK IS SUSPENDED OR ABANDONED FOR MORE THAN lBO DAYS. SUSPENSION OR REVOCATION MAY OCCUR IF THIS
PERmT WAS ISSUED ON THE BASIS OF INCOIIPLETE OR ERRONEOUS INFORMATION.
ANYONE PROCEEDING PAST THE POINT OF REQUIRED INSPECTIONS WILL DO SO AT HIS OWN RISK
SUBSURFACE AND ALTERNATIVE SEWAGE DISPOSAL SYSTEMS
(1) Permits shall be effective for one year from the date of issuance.
(2)
Upon completing the construction for which a permit has been issued the permit holder shall notify.the
Department by submitting the installation record form. The Department shall lnspect ~he constructlon ~o
determine if it complies with the rules contained in this division. If the constructlon does comply wlth
such rules, the Department shall issue a certificate of satisfactory completion, to the permit holder. If ~he
construction does not comply with such rules, the Department shall notify the permit holder and s~al1 requlre
satisfactory completion before issuing the certificate. Failure to meet the requlrements fo~ satlsfactory
completion within a reasonable time constitutes a violation of ORS 454,605 to 454,745 and thlS rule.
Setbacks - Subsurface SewaQe Disposal
From: Interior property lines
Edge of road right-of-way
Building foundation
Wells. other water sources
Seotic Tank
10'
10'
5'
50'
Orainfield
10'
10'
10'
100'
"
.,.) .
~ne ~ounty
-
..
CHECKLIST
PLUMBING/ MECHANICAL
.
"
APPLICANT INFORMATION:
L/,)o.t'CWy,(lJt L .:Pn~ u:L;
lName o~lrm-Please 'P~4nt) lMalllng AddreSS)
PLUMBING CONTRAcrOR
o Yes Firm
Address
o No o Self
MEGlANICAL CONTRACTOR 0 Yes Firm
Address
o NoD Self
Type of Fixture
pLUMBING
Number of Each
Total
Sink
Lavatorv [Wash. Basin]
Tub (with or without shower)
. Shower, separate
Water Closet [toilet/urinal)
Dishwasher
Disposer (garbage grinder)
Washin~ Machine
Water Heater
Floor Drain
Sewer--lst 50ft.
each additional 100 ft.
Water Service- -1st 100 ft.
each additional 100 ft.
Storm and Rain Drain--lst 100 ft,
each additional 100 ft.
Special Waste Connection '
Sewage and Sump Pump (e;ector)
Mobiie Home Sewer and Water
Other (specify)
SUB-TOTAL (Minimum $10.00)
u
o
n
J TOTAL FEE
Type of Equipment
I>1EGlANI CAL
Number of Each
Total
Mechanical Permit Base Fee
Furnace UP to 100,000 BTU/H
Furnace over 100.000 BTU/H
Clothes Dryer Vent
Bathroom Ventilation Fan & Duct
Ran~e Hood with Mechanical Exhaust
Wood Stove
Ai r Candi tioner Only
Heat Pump
Floor Furnace
Gas Piping System 1 to 4 Outlets
Per Outlet
Other (specify)
SUB-TOTAL
lruTAL FEE
OFFICIAL USE ONLY
Appli.;
Permit #
Cont. OSR#
lLlty or Town) lZlP Code)
Cant, OSR#
Fee On Each
$ 5.00
5,00
5.00
5.00
5,00
5.00
5,00
5,00
5,00
5.00
15.00
10.00
15.00
10.00
15.00
10.00
5.00
5,00
10.00
Fee on Each
$ 6.00
7.50
3.00
3,00
4.50
6,00
(',60
6,00
6,00
.50
$ 10,00
f
TRS. TT.
Plot;
Plan
Subdi visionyJA""'..... 1"., /'1^,"L..~^j F: >1.
Lot
C74-150
)11'\
Block 06
Vicinity Map
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Job Location
Permit II
Permit II
Permit Ii
(Address)
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!:/JOI/l~_ !NE COUNTY
OWNE_R-'~_ NAME a)~./I /
CONiRACI0R S NAME C/
l...::?>/??/ .P
SET BACK REQUIREMENTS
CL. FRONT ~~L. SlOE INTERIOR
WORK AUTHORIZED BY PERMIT " 1',/' ~
Od/l'//fi'~
DIRECTIONS TO SI~ .iJ~./~11 -d-
- - r7
.4~~1 ~~ ..at
SITE ADDRESS
..,"
'.
'rNSPECTION
.
RECORD
..
PHONE NUMBER
PHONE NUMBER
HPLUMBING FIXTURES
~ REAR
~t?~d (i/,1m tf!JmY.iOh))1//??/"",
d I' -v-<.
~l5S-Rd
PERMIT NUMBER
'FOOTING / FOUNDATION INSPECTION OR MOBILE HOME SET UP INSPECTION
Approved Correcti on Di sapproved Date Inspector
J1. A_
~ - ..;
CONCRETE SLAB / UNDER-FLOOR INSPECTION
Approved Correction Disapproved Date
Inspector
UNDER SLAB / PLUMBING GROUNDWORK INSPECTION
Approved Correction Disapproved Date
ROUGH PLUMBING INSPECTION
Approved ~ Correction
Disapproved
FRAMING INSP~TION
Approved 1/'. Correc ti on
St-II- 'Sf... VI" ~ - - .
'lNSULAtION / VAPOR BAR ER I
Approved /' Correction
LATH / GYPSUM BOARD INSPECTION
Approved ,:;' Correction Disapproved
FINAL PLUMBI~ INSPECTION
Approved ~ Correction
Disapproved
FINAL WASTE DISPOSAL SYSTEM
Approved Correction
INSPECTION
Disapproved
/
,V MOBILE HOME
Disapproyed
FINAL INSPECTION BUILDING
Approved I~Correction
,
CERTIFICATE OF OCCUPANCY
Approved Correction
Disapproved
Form C74-197
Inspector
DateUI- 9oz.. Inspector
~~
, -
Date ?_IJ-5?2..lnspector~
Da te .57-.2 </-X'2J ns pec tor
0ae
Date 1-2- 5?.z Inspector
/7A~~ /
'p-"-
Date//.) ./.(-%2-Inspector
y~-
Date
Inspector
Date I..:? -lsI- .?2kispector
Q.., d _
,
TEMPORARY CERTIFICATE OF OCCUPANCY
Date Inspector