HomeMy WebLinkAboutPermit Building 1993-7-6
OWNER: _ TItm cS ,4-vl> ,13lA-r" e..
ADDRESS:' ~& "i No ~"T 6- , . S'
CITy:-<"i7Jt<~C ri F-t-~'
-,
DESCRIBE WORK" <:;"/"c.JCLE FA-WI ~l7
NEW" >< REMODEL ADDITI.ON
RESIDE&.lTIAL'
PERMIT ApPLICATION'
Inspections: 726.3769
Office: 726.3759
LOCATION OF Pi;lOPOSED WORK'
.' )( ASSESSORS MAP' /B>~'2-
/SS
LOT:
-
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SPRINGFIELD:
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BLOCK'
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STATE:'O,l(
/2~/'jJ~I-Xe
DEMOLISH
OTHER'
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'. .... ..... ....
. ':JOB NUMBER -1-1&..~20 ."
225 Filth.Street
Springfield, Oregon 974(.7
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TAX LOT: 7~ "
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SUBOtVISfoN: t,,, <:'....c>"',o I>'i.:'..~oi.t.s'
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PHONE:
?~I-,06~,~"
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ZIP: 0~i:r
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CONST. .'
CONTRACTOR'"
CONTRACTOR'S NA~E.\(l ~ J1ZJ.i'I~EJS,
GENERAl' .~.'~~....~
, , , V.
PLUMBIN~' _..:.......
MECHANICAl'
ELECTRICAl'
FLOOD pLAIN: ..
ZONING CODE:U)~ .
. OF ~DRMS: .7-1).
U-fJ:
SECONDARY HEAT: I ~ .
,SQUARE FOOTAGE:d.3~
T~ request an Inspection, you must call 726-3769,.Thls'ls a 24 hour recording. AII.jnsp~ctions 'requested before 7:00 a.m. will be,
, . . " - . . ..
. made the'same working day, Inspections requested after 7:00 a.m.'wlll ,be: n'lade the following work day.
. . , " '. .
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QU~D "REA: ~~C'
. OF BLDGS:
,
OCCY GROUP:
H\'+f\~
" \
. OF STORIES:
. .
WAfER H~ATER:~;:;
'_ ~ Temporary ~leClric .
, 0 Site Inspection.:.... To be made
after excavation, but prior to
setting forms. ..
OJ Under~lab Plumbingl Electrlcall
. Mechanical - Prior to cover.
'.~ K7f F~otlng - After. tren~hes are
~excavated. .
o Masonry -. St.eel location, bond
,.' beams, grouting.
~Foundatfon - After forms are
~erected but prior to concrete
\1 '., placemenl. '
o .Underground Plumbing - Prior.
. to filling trench.
" ~Underlloo('Plumbl~echan~
: ~ ~ Prior to lII:::'Uldllon 01 Ul;:cr<lng.
, ",". ~
:'. . ., ,
.' ~ Post a':1d Be~m - Prfor to floor
: .~nsulat/on or dec;;kln~. .
,
~ "':"'r5<?f'Floor'lnsulatlon - Prior to
~ " . ~deCklng. .
1,.. . ,.. ,
-; '. :',... ~sanltary Sewer ~ Prior to fillil""!9
i.:;. :.,. ~trench. .
! .
t . ~.
f ;::. ~... S.torm Sew,:': - Prior to filling
~.~.: :. "..trench.. , '
~~. ~ "';' . . " '
~~i: j'~~:~~~une ~ prlor,l~ filling
~~..-. . .' I"
it~;~ ::~':~.:FR~U9,h ~Iumblng - Prl~r to
:('~'" .....( ~over" '
t~(~;' ::~,>. .. . '.. " .'
~ O'FFICE USE'C-. .
\\t\'
. OF UNITS:':' \ . <:) . .',
CONSi-~, TYPE:; "\/ AI.
HEATSOUR~E;:'~. FL
'E'
LAND:USE:
RANGF'
REQUIRED ,INSPECTIONS.
1'::A'ROU9h Mechanical ~ '.Prlor to
~cover. ." '".
~ Rough Electrical - pr'tor. ~~
~cover, ,', " '
. 1\7'1 Electrical Se~lce,~ M'US~ be
~approved fo .obialn' pe~inanent
electrical p<?wer. ". "',
'0 'Fireplace .....:..Prlor to facing
materials and framing Insp,
~raming'- Prior to co:,er.
~Wall/celllng 'I~SUI~tiOri - Frio'r I~
~~~ , '
l8:(DryWall - Prior to laplng.
. 0 Wood Stove' - Aller !n~tallatlon~; :.
. .
. .
. .
o Inse~ - Aftei flrep'ac~' approval
and Installation of uni.t." .
K7f Curbcut & Approach - Aft~r .
~ forms are ere.~ted but prior to
placement of' concrete.
I'\7r S!dewalk & ~riveway '''7 After
~xcavation is complete; .torms
and sub-bas'e."materlal.ln place. .
o Fence -.Wh,~n comPI.ete~:
@},tr~et Trees.~..Wh~~ ~i~ r~'qUln~d..'
rees are planted. " ':, '.
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EXPIRES
. PHONE
, .,.....
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,."
, ,
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"'..
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;
:..,
, .~ Fi~~ PIU~bing -' WhEm air.
~ plumbing work is complete.
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, . " ,1':71 Final 'Electrical - Whe.~- all
. ~tectrlcal ~ork Is complet,~, '
c.
~. ,
Final M'cchanlcal - When all'
_ . echanical work is cOf!lplete.
.. r'YrFlnal Building - When, all .
T""'requlrCd inspections have be~n,
. . approved and building is .;
completed.
oOlher
MOBILE HOME INSPECTIONS
o BI~ck'lng and Set.Up -' When all
. bl,ocking is complete.. '.
'. 0 p'lumblng Connections'- When.
. , . home has been connected .to '
. water and sewer. .
o Elect~ical Connection *"Whe0
. bl,ocklng, set-up. and plumbing'
. .. inspections have been approved',
, anq th~ home is 'connected to'
the' service panel.
'~,
, ."
':D Final,- After all required
.' . inspections are approved and
. 'Porches, skirting, decks; and
:. venting' have becn'instalied. .
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'c IS THE PROPOSED WORK," THE)
HISTORICAL DISTRICT. OR ON
THE HISTORICAL REGISTER?
If yes, this application must be signed
and approved by the Historical
Coordinator prior to permit issuance.
Lot faces Lot Type . Setbacks
Lot sq. Itg. Interior I P.L HSE GAR ACC
:L IN
Lot coverage Corner
Is
Topography Panhandle
33/ Iw
Total height Cul.de.sac
IE
{f~~2
..9))
~.'1M
(A) 1.!J3.!J6
SYSTEMS DEVELOPMEJH CHARGE (SDC) 1/5
. Tf 'Z'!>1t."'~ .I.
1$ (B) 1#/14ff':~
BUILDING PERMIT
ITEM SQ. FT,
Main
--L B 1'J1?
~7Ca-
Garage
Carport
Total Value
Building Permit Fee
State Surcharge
Total Fee
PLUMBING PERMIT
ITEM
Fixtures
Residential Bath(s)
Sanl tary Sewer
Water
Storm Sewer
Mobile Home
Plumbing Permit
State Surcharge
Total Charge
MECHANICAL PERMIT
Furnace
Exhaust Hood
Vent Fan
X $/ SQ. FT.
~..z.o
-?-4.4:I
N' ,~
FT.
FT.
FT.
(C)
Dryer Vent
Wood Stovellnsert/Fireplace Unit
N'
'2..
Mechanical Permit
Issuance
State Surcharge
Total Permit
Mobile Home
MISCELLANEOUS PERMITS
(D)
State Issuance
State Surcharge
Sidewalk 1:8- It
Curbcut . ':){")
It
Demolition
State S~rcharge
Total Miscellaneous Permits (E)
VALUE
/10/ /t'DO
r
~ /2'2...
FEE
B~5D
{Q/1.SJ
-qL1?.~
~.k~
I n (j:)
+.~)
,...-;;, (:9-t)
,3.CO
/C} /5'0
/0.00
;~
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APPROVED'
BUILDING VALUE, PLAN CHEGK
AND BUILDING PERMIT
This permit is granted on the express condition that the said
construction shall, in all respects, conform to the Ordinance
adopted by the City of Springfield. including the
Development Code, regulating the construction and use of
buildings, and may be suspended .or revoked at any time
upon violation of any provisions of said ordinances.
2-9~ ,CJIh.
t:. -Ib -7'3
~7/3
Received ~~
-~.~~
Plan, Reviewed By
Pian Check Fee:
Date Paid:
Receipt Number:
. -7A(~:J
Systems Development Charge.is duc'on all undeveloped
properties within the CitY,limits whi~h.are being improved.
ADDITIONAL COMMENTS
1!J1JlmOO;c,bmnl'f' )
\ 914-7: II oc:{)
j
J _'
u.ZIDN '1.-, I)01o)~ !.9!2~
-p~
~A..t' A7~ EI rr;:'l){?(CA( ~/f&22//-.
_1_5' 2-f~/,.e&)"
By signature, I state and agree, that I have carefully examined
the completed application and do hereby certHy that all
~n'formatlon hereon Is true and correct, and I further certify
that any and all work performed shall be done In accordance
with the Ordinanc~s of the City of Springfield. and the Laws
of the State of Oregon pertaining to the work described
herein, and that NO OCCVPANCY will be made of any
structure without p~rfTljssion of the Building Safety Division.
I further certify that only conlractors and employees who
are In compliance with ORS 701.055 will be used on this
project.
I further agree to ensure that all required Inspectlofls are
requested at the proper time, that each. address is readable
from the street, that Ole permIt card Is located at the front
of the property. and the approved set of plans will remain
on the site at all times during constructlon.
,~ a daJ-
;,; 1'113
~~nature
/
3t,n.BS . Date
14 .:=1)
f=)/...3S
3/34.~o
TOTAL AMOUNT DUE (excluding electrical)
(A. B, C, D. and E Combined)
VALIDATION: r<;,/\
RECEIPT NUMBER ~y )nL....
DATE PAID ~J. .~/~-
AMOUNT REC' ~ I ',-:I)i .ld)
RECEIVED BY (X /
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Permit No: G{ ~rR8 0
Address: \ -= 'M Q \ \- ~[)\lli/Rn Oo.t
Issued bl:. ~M. ) D::D!J ./()q:,
FOR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4). requires residential construction permit
applicants who are not registered with the Construction Confractors Board to
SigR the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement, will be
filed with the permit.
~i."IX ~PPI:C:~~~ ~~::k:'i:,n:r i:;lila:e:~;:~n1 t::dc:~:~:e:t::~:t::e~A or 3B:
3. A.I
I I understand that I must register as a constructioR contractor he structure is sold
, I or offered for sale before <l[ upon CDmPletiO,n. .
I ~ I My general contractor is'- \Q \111 -\/ ~ _' _
Contractor registration number \ ~~ Q, /l9-A/- J 8/ bA ~
I will instruct my general contractor that all subcontractors whc work on the struc-
ture must be registered with the Construction Contractors Board.
2. I
OR
3. B.'
I I will be my own general contractor.
If I hire subcDntractors, I will hire only subcDntractDrs registered with the CDnstruc-
tion Contractors Board. If I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractDr.
I hereby certify that the above information is correct and that I have read and understand
the Information Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
(L1'~-O '14:;
~ature of Permit Applicant
LL i, /11.:1
v1D~W
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91 ,.
WHITE COPY TO ISSUING AGENCY PERMIT. FILE
PINK COPY TO APPLICANT
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INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
....:; - )
NOTE: This InforlT!ation Notice to Property Owners About Construction Responsibilities
was developed by the, Construction Contractors Board in accordance with ORS 701.055(5),
passed by the 1989 Oregon legislature.
If you are' acting as your own contractor to construct a new home or make a substantial improvement to an
existing structure, you can prevent many problems by being aware of the following responsibilities and areas
of concern. '
EMPLOYER RESPONSIBiliTIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction or improvement of a residential structure, you will, in most instances, be ruled to be an
"empIDyer" and the people you hire will be "employees". As the employer, you must comply with the following:
Oregon's Withholding Tax law: As an employer, you must withhold income taxes from employee wages at
the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the
tax from your employees. For more information, call the Oregon Department of Revenue at 378-3390.
Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment Division DHR
at 378-3224.
Workers' Compensation Insurance: As an employer, you are subject to. the Oregon Workers' Compensation
Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers'
compensation insurance, you may be subject to penalties. and will be liable for all claim costs if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 373-7434.
U.S, Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages.
YDU will be liable for the tax payment even if you didn't actually withhold the tax. For more information, call
the Internal Revenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requirements that may be brought to your attention through inspections.
Liability and Property Damage Insurance: Contact your insurance agent to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint overs pray, water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees: Make sure you have sufficient time to supervise your employees.
^
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
If you have additional questions, write to:
Construction Contractors Board
700 Summer SI. NE, Suite 300
Salem; OR 97310-0151
Phone 503-378-4621
0244J 10/24/89
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. .B NO. CJ?JO 8Z0
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE
WORKSHEET
(COMMERCIAL & RESIDENTIAL)
'.
NAME OR COMPANY: .JAMes iJL.A-INE I-!A~T
LOCATION: 4{,1/ HoLLY S-r.' / 'ifcr2.tJ'5l1. - 7 FM
DEVELOPMENT TYPE: LPI<. - ^' €- vJ Sp,e,
BUILDING SIZE: LOT SIZE SQ. Ft.
1. STORM DRAINAGE ?J<lsf- (0~~~0-
~ ,
IMPERVIOUS SQ. FT. X $0.192 PER SQ. FT.
2. SANITARY SEWER-CITY
NO. OF PFU'S Z3 X $39.78 PER PFU G q/<-f &f?)
(See Reverse) ----- ---
3. TRANSPORTATION
NO OF UNITS X TRIP RATE X COST PER TRIP
/ X /. 0-05 X $401.05
G <f()3.~
--- ---
x
X
X $401.05
X $401.05
$
~
SUBTOTAL (ADD ITEMS 1,2,
$ . - .tP
_ . _.-fr.IJ 17
& 3) $~..-.- /1?f/-
4. ADMINISTRATIVE FEES
BASE CHARGE (SUBTOTAL A80VE) X .05
~ fJ'"
<$ ~) '11-
----------
TOTAL-CITY SDC $~ -z..Ostl
5. SANITARY SEWER-MWMC
'2. '1-<..
NO. OF PFU'S 'Z.3 x $13.62 PER PFU + $10 MWMC ADMIN. FEE $ .,2'?-
(Use PFU Total From Item 2 Above)
MWMC CREDIT IF APPLICABLE (SEE RE~RSE)
/~ ~ak ~/}:/"p
SDC Coordinator
$ '3/ ~
TOTAL-MWMC SDC~1-~ ~
~,..~ ~b
TOTAL SDC $ ~ - 2?/'2--
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FIXTURE UNIT CALCULAT- TABLE: Number of New Fixtures X .qUivalent = Fixture Units ~OTE:
For remodels, calculate only the NET additional fixtures) .
FIXTURE TYPE
NUMBER OF
NEW FIXTURES
Bathtub,............ ........ .......... ............. ........ ..................
Drinking Fountain...... ..............,..............,.... ..... ........
Floor Drain............,......,........,......,..,.....................,:..:'
Interceptors For Grease/Oil/Solids/Etc.................
Interceptors For Sand/Auto Wash/Etc........:.......:.
Laund ry Tub /Clotheswasher......,.....,..................,...
Clotheswasher - 3 Or More.....................................
Mobile Home Park Trap (1 Per Trailer),.................
Receptor For Refrigerator jWater Station/Etc........
Receptor For Commercial Sink/Dishwasher /Etc..
Shower, Single StalL...................................,.....,....
'Shower, Gang................................... .......................
SinK, Bar, CommerciaL..............,..,..,......................
Urinal, Stall jWalL ............................................,........
Wash Basin/Lavatory, Single,...........,...........,.........
Water Closet, Public Installation.............................
Water Closet, Private...............................................
Miscellaneous:
I
)
- /
I
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~
TOTAL FIXTURE UNITS
.
UNIT FIXTURE
EOUIVALENT UNITS
2 ;j..
1
2
3
.6
2 2-
6
6
1
3
2 2-
l/Head
2 Z
2
1 ~
6
4 /2-
2.3
CREDIT CALCULATION TABLE: Based on assessed value. If improvements occurred alter annexation date in table,
Ealculate credits separates.
Year
Annexed
Rate per $1,000
Assessed Value
Year
Annexed
.1
1979 or before
1980
1981
1982
1983
.1984
$2.83
2.76
2.71
2.60
2.46
2.33
1985
1986
1987
1988
1989
1990
1991
Rate per $1,000
Assessed Value
$2,16
1.90
1.60
0,25
0.87
0,50
0,16
1
Credit for Parcel or Land Only If Applicable
=
~/'.!
Improvement (if after annexation date)
2 ' g3 X LJI 0
(Rate X Assessed Value)
X $
(Rate X Assessed Value)
CREDIT TOTAL
=
= $ '3,1).
..',
RUNOFF COEFFICIENTS' FOR STORM DRAINAGE.
',.
.,
Residential........................................................ 0.4
CommerciaL.................................................... 0.9
IndustriaL...... .............. ..................................... 0.45
GovernmentaL.. ,.....:... ,...................... .............. 0.5
IMPERVIOUS AREA = TOTAL LOT SIZE X RUNOFF COEFFICIENT
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. .OB NO. CJ??O 87.0
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE
WORKSHEET
(COMMERCIAL & RESIDENTIAL)
NAME OR COMPANY: SA-MF':S ~ E:L.1tINE: HA~T
LOCATION: 41,.// ~LL.Y S-r. /f{(J7.o'5l1. -7F/JtJ
DEVELOPMENT TYPE: LPI< - New SrI<.
BUILDING SIZE:
I. STORM DRAINAGE
IMPERVIOUS SQ. FT.
LOT SIZE
SQ. Ft.
?? tp,/ 0
X $0.i92 PER SQ. FT. C;:.Jo'iV
NO. OF PFU'S
(See Reverse)
3. TRANSPORTATION \ \.. ,..,VY<
NO OF UNITS AT~ C'd-sT PER TR~~ 1\
/ \' X / ~ IX $401.05 -\\\
rt-l V X $401 $
L; \ '- X~f4I.05
SUBTOTAL (ADD ITEMS 1,2,
7.?>
(:11t.f'tV
2. SANITARY SEWER-CITY
G <f03'~
-- --
$ ~
$ ~
& 3) $ '2-0?-"2. 11>:1.
/
4. ADMINISTRATIVE FEES
BASE CHARGE (SUBTOTAL ABOVE) X .05
~)
TOTAL-CITY SDC $ i'7.~"Il
5. SANITARY SEWER-MWMC
NO. OF PFU'S 'Z-~ x $13.62 PER PFU + $10 MWMC ADMIN. FEE $ ?7.?~
(Use PFU Total From Item 2 Above)
MWMC CREDIT IF APPLICABLE (SEE REVERSE)
$ '3/ ~
TOTAL-MWMC SDC~~~1Jt)
--------
TOTAL SDC $ -Z '-II is '!9
Ie! A ~~ ~ /11 /1~
-cr Kip Burdick
SDC Coordinator
~
FIXTURE UNIT CALCUu\T. TABLE: Number of New Fixtures X .qUiValent; Fixture Units (NOTE:
For remodels, calculate only the NET additional fixtures) ...., . .
NUMBER OF UNIT FIXTURE
FIXTURE TYPE NEW FIXTURES EQUiVALENT UNITS
.'.
."
/
2
1
2
3
.6
2
6
6
1
3
2
1 /Head
2
2
1
6
4
:z..
Bathtub. ......... ...... .......... .................. .....,....................
Drinking Fountain................ ............... .................. ....
Floor Drain....,...........................................,..........:.:..:'
Interceptors For Grease/Oil/Solids/Etc.................
Interceptors For Sand/Auto Wash/Etc........:.......:.
Laundry Tub /Clotheswasher....... ............... .............
Clotheswasher - 3 Or More.....................................
Mobile Home Park Trap (1 Per Trailer)..................
Receptor For RefrigeratorjWater Station/Etc........
Receptor For Commercial Sink/Dishwasher /Etc..
Shower, Single StalL...............................................
Shower, Gang....................................................,.....
Sink, Bar, CommerciaL..................,.................:......
Urinal, StalljWaIL.....,..........................................,...,
Wash Basin/Lavatory, Single....,............,...............,
Water Closet, Public Installation,..........................:.
Water Closet, Private.................................,.....:.,.....
Miscellaneous:
I
I
2
2.
I
'2.
?
~
/2-
.. ?>
"
,
. /
.'/',
j ".
TOTAL FIXTURE UNITS
23
,
f
CREDIT CALCUUl.TION TABLE:
r~itSy::arates.
I Annexed
Based on assessed valu~. 'If improvements occu;red after annexation date in table,
. ..".
.. l .
I
Rate per $1,000 ,f Year
Assessed Value Annexed
$2.83 1985
2.76 1986
2.71 1987
2.60 1988
2.46 1989
2,33 1990
1991
"
Rate per $1,000
Assessed Value
1979 or before
1980
1981
1982
1983
L..1984.
Credit for Parcel or Land Only If Applicable
$2,16
1.90
1.60
0.25
0.87
0,50
0.16
-
Improvement (if after annexation date)
2 . 8'; X $ -1/ . ()
(Rate X Assessed Value)
X $
(Rate X Assessed Value)
CREDIT TOTAL
;
~I ~
;
3 13
= $ /-
RUNOFF COEFFICIENTS FOR STORM DRAINAGE,
ResidentiaL..................................................... 0.4
CommerciaL................................................... 0.9
IndustriaL........................................................ 0.45
GovernmentaL................................................ 0.5
IMPERVIOUS AREA = TOTAL LOT SIZE X RUNOFF COEFFICIENT
.1.....
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SPRINGFIELD
.~~ It
"0'"
ii-'" ~~'
225 FIFTH STREET .c" \ . n~ ..- ELECTRICAL PERMIT APPLICATION
SPRINGFIELD, OREGON 97477,,,;;'(.'"" '..' vY -- qv)NQ/)()
INSPECTION REQUEST: 726-3769 7-'1'1' --\01. _____Ci.tf:lob Number I T"b<1
OFFICE: 726-3759 -').' V:fb....---- =
. 0,,0-----: ~\P,:.~P--3. COMPLETE FEE SCHEDULE BELOV
1. }"<1CATJ;ON. 01' :r.NSTAL~~~_"'I\1-CC-\
L..\-\,,\ \ ~ Lt A '::5 A. New Residential-Single or
I ~[<'1~rf. ~. ~~. N~- 1'~O() Hulti-Family per dwelling unit.
Service Included:
Items Cos t
. ro>> ~CRIFTiQl!1 ~ 3V) Cc T_.
~~\~ ~O~ 0, O~c+ \SUY\)
",
Permits are non-transferable and eKpire
if work is not started within 180 days
of issuance or if work is suspended for
180 days.
2. CONTRACTOR INST^\'-tTION ONLY B.
Electrical contractor~,~~ ~W
Address ~\) ~\0', ,1'toll '---'
City~rl . Phone I\Q~
Supervisor License Number fJ (d) LS
EKpiration Date' l().\ .qS
Constr Contr.. Number '6fSlQ~
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Signat~ ~~~ Electrician
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~ALLATION
EKpiration Date
The installation is being made on
property I own which is not intended
for sale, lease or rent.
Owners Signature:
DATE~-----~----77-~~~ ~~-=-----
RECEIPT I: '-..=::.,//. . . ~F ) 7 /?
RECEIVED B~ l~UU .
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereof
Each Hanuf'd Home or
Hodular Dwelling
Service or Feeder
$ 85.00
Sum
8c:!J
46
'-~
$ 15.00
$ 40.00
Services or Feeders
Installation, Alterations
or Relocation:
200 amps or less
201 amps to 400 amps
401 amps to 600 amps
601 amps to 1000 amps
Over 1000 amps/volts
Reconnect Only
$ 50.00
$ 60.00
$100.00
$130.00
$300.00
$ 40.00
C.
Temporary Services or'Feeders
Installation, Alteration or Relocation c)
200 amps or less ~ $ 40.00 ~[) P
201 amps to 400 amps $ 55.00
Over 401 to 600 amps $ 80.00
Over 600 amps or 1000 volts see "B" above
D.
Branch Circuits
New, Alteration or EKtension Per Panel
'One Circuit
Each Addi tional
Circuit or with Service.
or Feeder Permit
$ 35.00
$ 2.00
E.
Hiscellaneous (Service/feeder
-Each installation
Pump or irrigation
Sign/Outline Lighting
Limited Energy/Res
Limited Energy/Comm
not included)
5.
$ 40.00
$ 40.00
$ 20.00
$ 36.00
I r;n_CO
~ . c., C-1
I f [06 7{..J
SUBTOTAL OF ABOVE
5% State Surcharge
TOTAL .