HomeMy WebLinkAboutPermit Building 1986-10-2
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\ INSPECTION LINE
726-3769
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Job Address
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CITY UF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
liater Heater
Range
~~ ~ ~ J I~'::~~~ION LINt
726-3753
Sq. Ftg. "'ain
~q. Ftg. Access.
Sq. Ftg. Other
New Add Alter Rep.
I -Fence Demo Change/Use
,/ -Other- -
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10
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legal Description
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T\ RJG
Sk:-~ Qk
ValUE of f10rk:1! 1 () 01 ~
Owner, 'Yt::~}J ~ ) r=. /U ~ (\ d \P -\ I-.J
.., ''-P BuilciinQ Pennit Info: Describe Work(Le.. Build Single
, Address 10'-\ ':) IV. 0\-0 Si'Ar....r.: R.O, Phone'1."_~I"4 Familv Residence liith Attached Garaoel
MT. '51.l-f->..'S,R ,c.-A. ., lo[)r~'1 ~ oFf' ':"..\ I.Ol!:t ROOFlt0C..- .... RP ~
Construction Lender '".)\'1'\"\ QIlJ~~ -t'iI'@_AlH\& ::'-Pl--'l' ~p
':O\.l-c~T. (;,'l..A) uJ.~.) c-\.A""~ ~ 1'\"
(lies. no.l (axo;r~s) (ohone
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[1,1
Address
Ut,IGN I EAr~
(namel
Phone
(address)
Primary
Structural
Electrical
Mechanical
CONTRACTORS
~eneral)
.\
tnamel
(address)
(1;~c;,. M.
(pxnirpc:,)
(ohonp no. )
~
L1\D'll-\ (')fQ'')loJ R}('j,
E\)~",l=: nee. .
en >-i () 1..
"I"l (,....
\\1 '-1\ ~I^
-"44-0'l-l.,"
Qr-.1S (.<.C\r-.jO:\ t.J(y
Plumbina
El ectri ca 1
~'echanical
PLU11B I NG
ELECTRICAL
MECHANICAL
NO,
FEE CHARGF Nn
'Ore r"'IRliE. JlO....I
n~1=" Irl-l~
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
(1 bathl
Duplex (1 bath) each
Additional bath
SERVICES
Recessed wall
~nar.p hp~tpr ann vpnt
Storm Sewer
I
I
I
I
Of
amps.
Appliance vent
S~Daril.te
Stationary evap.
cODl~r
Vent fan with
sinole duct
Vent system apart from I
hpatinq or A.C.
Mechanical exhaust
hood and duct
Sewer
Temporary Construction
Change in existing
rf:'s.;rteJlce
mUltifamily. comm. or
tnrlustrial
~Iater service
COMfI,/IND, FEEDERS
Install/alter/relocate
rli~trih_ fppdpr~
Wood stove/heater
Of
amps.
ISSUANCE OF PFR!11T
TOTAL CHARGES
WHERE STATE LAW REQUIRES
~hall not be valid until the
TOTAL CHARGES
TOTAL CHARGES
that the Electrical work be done by an"Electrical Contractor. the electrical portion of this permit
label has been signed by an Electrical Supervisor and returned to the BUilding Division
I HAVE CAREFULLY EXAf1INEO the completed aprlication 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 OCCUPAtKY 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.
IWIE(please print) :\\ M f,? ..ljS:S SIGNATURE ~\~"' ~~..J~'\)
FO~ OFF I CE USE DIlLY I \
Zone Tvpe/Const. Units Sq. Ftg. r~n ,x
Fire Zone Bedrooms Dccy Load Sq. Ftg. Access x
Flood Plain Stories Occy Group Sq, Ftg, Other x
DATE~
Value
Value
Value
TOTAL V ALUA Tl ON
BUILDING PWlIT
Charges and
Surcharges
/ -; "'0 P1 an Ck. Conm/lnd
~~ '-J' 65%/B1do Per Fep
----n~~50- ~~~~B~~~ ~~~ Fee
Fence
Systems Development
Charge (1,5~) ,
PLU!~BING PERMIT
Charges and
Surcha rges
D~R1o
'Sidewalk
ELECTRICAL PERIHT
Cha rges and .
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
A/C Paving
____________1 Curb Cut
I
Total Comb. Permit
....,
I Co5, dU
I
TOTAL
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Applicant to furnish
A. Job Address
8. legal Description
I, exampIe- Tax Lot 100, Lane County Map Reference
I! U3 43
2, examp]e- Lot I, Block 3, 2nd Addition to
springtield Estates "
C. Name, etc. of owner and construction lender
D. . Energy Sources
1.' examp 1 e~ hea tie 1 ectri ca 1 ceil i nq/or forced air Qa5
2. exampJe- waterheater/electrlcal/or solar
E. Square footage or valuation, etc. -
I, examo1e- 1250 sq, foot house, 500 sq, foot garage
2. example- if new project, ch~ck-new - if addition,
check add, etc.
F. Building permit information:
1:' 'examole - construct single family ho~se with an
. attached garage . . - f-
2. examEle - remodel existing garage into family room
3. exam~le - 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, 'OESIGN TEAM AND CONTRACTORS
To avoid design or construction delays. Building4
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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ID')'~&
V, FOR OFFICE USE ONLY
Permit Clerk
cI/
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
.
PLANS REVIEWED BY:
name
signature
date
,