HomeMy WebLinkAboutPermit Building 1984-3-7
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I IrlSPECTIDrI LIIIE
726-3769
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CITY OF SPRINGFIELO
COMBHIATION APPLICATION/PERMIT
E!IERGY SOURCES:
Heat
Hater Heater
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INFORJIATION UNt
726-3753
Sq. Ftq. 1.lain
~q. Ftg. Access.
Sq. Ftg. Other
New Add Alter Rep.
-Fence Demo Change/Use
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Owner P /H/L lit; I< (/1'1-777-
Address:;~~/rV/~ 7777
Construction Lender .
Job Address
Ranqe
Structura 1
.,
liI'fjNMeY'1 Y
ValuE. of Harle
13':000
Pho -''2/ /"'" Builliind"Pennit Info: Describe Work(Le.. Build Single
ne /. bbtY) Familv nes;dence \-lith ,d.ttached Garace)
IkIJJ;c3n 011. II ;Y'U'f'~
"7?1 'P'hrV/p,,j Mo~} %0 Home
Phone );6 rf(
(address) -' l1ic\- no.) (exo;resl
21 z.. Q -:=yfJlof/ 9 5 g6
(ohane no. \
7 tjj -03/9J
Address
Ut::'lliN TtAH
(name)
Krqn{' /.,
Primary
Elec~r;cal
11echanical
CONTRACTORS
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(name)
(address)
(lir.~. no.)
lexoirf's\
{ohnnp no \
Plumbino
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726 6/N}~
Genera 1
Electrical
( r
~'echanical
PLUllBING
ELECTRICAL
MECHANICAL
NO.
HF CHARGE NO
~~~ r~ARr.~ Nn
~[:'~ rUAQr.c
Each single fixture_
Residence of
SQ. FT.
furnace/burner to
BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
(] bath 1
I Duplex (1 bath)
IAdditional bath
."t!~1 ~Iater service
~~I Sewer
IStorm Sewer
SERVICES
Recessed wa 11
~n~ce hp~tpr ~nrl vpnt
each
?({iJ
00
h~,
ITempOrary Construction
IChange in existing
rpc:,; denr:p .
Imultifamily, camm. or
Inrlu"tr;<'ll
Of
amps.1
Appliance vent
seoarate
Stationary evap.
cooler
Vent fan with
sinole due-to
Vent system apart from I
heatino or A.C.
I Mechanical exhaust
hood ilnd rIlJct
I \'Scad stove/heater
1
I
I
I
I
amps.l
\\ I\\~ SEv\WF.' \)r;t> \\0::'
I I
I I
TOTAL CHARGES \ ~ ~/>o TOTAL CHARGES \ \C1,- TOTAL CHARGES
WHmE STATE Uti 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
COffi1./INO. FEEDERS
Install/alter/relocate
rl;~tr;n fpprlpr~
Of
ISSUANCE OF PFR!1lT
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 UO OCCUPAI~CY 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 OP.S 701.055 will be used on this project.
IIAHE(please print) PAOI_ IIoRI/,I'f7)/~ SIf,IIATURE ~J //f'w DATE :;hbY"
FOr, OFFICE USE/OIlLY
Sq. Ftg. f1ain
Sq. FtfJ. Access
Sq. Ftg. Other
/ I
ZoneJ'''_\\~Y''
Fire Zone
F1 ood P1 a i n
Tyoe/Const.
Bedrooms
Stories
Units
Occy load
Occy Group
'If Value
x Value
x Va 1 ue
TOTAL VALUATION t'S. c:co-
BUILDIrlG PERfIlT Plan Ck. Comm/Ind Y6 ,tlr:> Pb 3-;1 Shstems Development ?<LS,CO
Charges aoC: 65%/Blrln P~r Fp~ C aroe (1.5%) ,
Surcharges ------------""""i'ian Ck. Res ~~< SY!
30%/Bldo Per Fee
PLU'1BING PERMIT \.~'5 OU Fence ilirJ:.. i11,.P Ir,RS P, ,::),0
Charges and
Surcharges --- ~:-LlO--1 D~A1O I I
ELECTRICAL PERIHT ___\\0. cO I Sidewalk IE~\'S\, I
Charges and
Surcha rges ~. '-I.() I A/C Paving IE'k\~ ITotal Comb. Permi t L\ ?lJ. c;9
I1ECHAN I CAL PERMIT I Curb Cut 15'1..\'&, ,-
Charges and ~
Surcharges ------------, I I'OTAL
-
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Applicant to furnish
A. Job Address
B. Legal Description
1. example. Tax Lot lOa. Lane County Map Reference
II OJ 43
2. example- Lot 1. Block 3. 2nd Addition to
~prlngtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. examole. heat/electrical ceilinQ/or forced air qas
2. examole- waterheater/electrlcaJ/or solar
E. Square footage or valuation, etc. -----
1. examole- I2S0 sq. foot house, SOO 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. examEle - 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 TE~1 ANO 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.
fJd~ I)
lod-LPI~
V. FOR OFFICE USE ONLY
Pennit C1 erk
3 ~I (fry)
~
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit app1 icant exempt from registration with the Builder's Board because':
Additional Project Infonnation:
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PLANS REVIEWED BY:
nameD~\) \D Yl"'E'" \\
signaturD('.A.J"''\.~ '--... \--
d~~e ~- \rt - ~L\