HomeMy WebLinkAboutPermit Building 1984-5-3 (2)
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CITY OF SPRINGFIELD
CDMBIIIATION APPLICATION/PERMIT
EilERGY SOURCES:
Heat
Hater Heater
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, INSPECTION LINE
i 726-3769
3 if ~- G C; <;0
Job Address 336 D ~ "f
Legal Description\\] ~"::' ,;<=<: ~,,(.:::~ 1 ~\'\ti'
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INFORllATlON ll,\t
726-3753
Sq. Ftc. 1,lain
~q. Ftg. Access.
Sq. Ft9. Other
r~ew Add Alter P.ep.
--Fence Demo Change/Use
Other- -
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Owner j 1:z1"cR.. Le~
Address,:2 9 7 ,5' G-,)~" ~
RanQe
Valut of Hor~~~
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Pho L/l?/f BuilGlna Pernlit Info: Describe Work(i.e.. Build Single
ne 11) 'T 'S'(" . Eamil y nes; dence I-lith Jl..t tached (iaraop \
'. ., U /G.d.ct_'l-\8-nJ '-1-0 hcVu CUlfLLU,
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Construction lender
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Address
Ut~HiN TEAf1
( ohane
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Primary
Mtl.,,~/'p
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Phone
(address) (lies. no.) (exoires)
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(name)
Structura 1
Electrical
f1echanical
CONTRACTORS
(name)
(address)
(lie". no.'
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General n... '" '1
Plumbina ~u....c::;.p~
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Electrical _<; ~_I'I ~ r
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1-..^- eke. t/ .2/ ,;:;0 Ru..c I-c Sf
ITemporary Construction
IChange in existing
rpsinJ'.n('p
Imultifamily, camm. or
Tnn1J<:t.ri"l.l
~lechan; ca 1
PLUI1BING
...J!Q."I
:<., I Each single fixture
IRelocated building
(new fix. additional)
IS. F. Residence
(J bath \
I Duplex (l bath) each
I Additional bath
l~rater service
Isewer
FFF I f.HARr,E
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Residence of
New circuits alts.
or extensions
I SERVICES
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Storm Sewer
IOf
COMI'I./I NO. FEEDERS
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L;<6'-1-7~qO I
~X'~-72 78'i
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_27 i?</
ELECTRICAL
MECHANICAL
SQ 0 FT.
"-ELI"I
furnace/burner to
BTU's
Floor furnace
and vent
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Recessed wall
~o~rp hp~tpr ~nrl vpnt
amps.1
Apoliance vent
c:.plJar<ltp
Stationary evan.
cooler ~ .
Vent fan with
sinole duct
Vent system apart from
heatino or A.C.
Mechan1E,il exhaust---
hood M'ln dur:t.
I Hood stove/heater
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Electrical Contractor, the electrical portion of this perm1t I.
Superv1sor and returned to the BU11ding Division
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Install/alter/relocate I
rti"tritL fpprtpr"
amps.
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Of
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TOTAL CHARGES TOTAL CHARGES
WHERE STATE L\I~ REQUIRES that the Electrical work be done by an
shall not be vali1 until the label has been signed by an Electrical
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ISSUANCE OF PFRl1lT
TOTAL CHARGES
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I HAVE CAREFUllY EXM1INEO the completed applicat10n for perm1t, and do hereby cert1fy that all information hereon 1s 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 Soringfield and the laws of the State of Oreqon pertaining to the work described here1n. and that fW OCCUPArKY w1ll be made
of any structure without the perm1ssion of the Build1ng Divis1on. I further certify that my reg1strat10n with the Builder's
Board is in full force and effect as required by ons 701.055, that if exempt the baS1s for exempt10n 1s noted hereon, and that
only subcontractors and employees who are in compliance with OP.S 701.055 will be used on this project.
'lGIIATURE__~__/~_ _ _
F~~ ~rF!C: ~rg Q!i(r-- / ~ -
Sq. Ftg. 11ain x
Sq. Ft9. Access x
\'" - -:... Sq. Ftg. Other ,x
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llAI-lE(please print) ..J ~V(-(\ ~ ><e.. '-?
._n_
Zone ''''-..-
Fire Zone
Flood Plain
Type/Const:-.Jh \, '--......
Bedrooms ---
Stories
Units
Occy load
Occy Group
BUILDING PERNIT
Charges and
Surcharges
,.~ "'___. Plan Ck. ConrnlInd
'-., - . 65%/Rldo Per Fpp
-------\()---PTan Ck. Res
\, '-- 30%lBldo Per Fee
-.' Fence
------------1 Dt1lno
\ .,-:.... I S1dewa 1k
------------
I A/e Pav1 ng
L '....' -'; I Curb Cut
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PLUt~BING PERMtT
Charges and
Surcha rges
ELECTRICP,L PERI~lT
Charges and
Surcharges
I1ECHANICAL PERMIT
Charges and
SurCharges
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OATE..0h Y
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Value
Value
Value..
TOTAL VALUATIorV:;>.., "'-/
0---3,K') f51-J./fr;?;)' Cc.-
/ V 'l"". Sys te~s Deve I opment ;. \', ::..,
01 c71 .1 Charqe 0.5%), )
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Total Comb. rermit
I TOTAL
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
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 Addition to
Sprlngfield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. example- heat/electrical ceilinq/or forced air Qas
2. exa~le- waterheater/electrlcal/or ~
E. Square footage or valuation, etc.
1. examole- 1250 sq. foot house, 500 sq. foot garage
2. exam~le- if new project, check-new - if addition,
check add. etc.
F. Building pennit information:
1. example - construct single family house with an
attached garage
2. examole - 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 TEM4 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
20 If the item(s) to be installed are not covered on
the abbreviated schedules you should consult the
fu 11 schedu 1 es
Co BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
O. 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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V. FOR OFFICE USE ONLY
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Permi t 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's Board because:
Additional Project Information:
PLANS REVIEWED BY:
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