HomeMy WebLinkAboutPermit Building 1979-10-17
Job Address ~11"8.8 a~rtdf.WA~. ~
Legal Oescription1:1.12on 17- O:j- Z2-Z.
CITY OF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
ENERGY SOURCES:
Heat E//!.Go
tlater Heater
Range Ekt;...
';>lu, of Hark:
R"Co..F,eI.C G. If'30.ooo "
Z2.~A1 ""O~~A.,,,Phone'10"''''' Buildino Pennit Info: Oescribe Work(Le., Build Single
.,.,.. ~I .,'~.. w -.~ Familv Res;dence Hith Attached Garaee)
~VC:M'S/e>N C>~ V~.z;...,..c;., ~
IN ~':S7:. ~/~ ;:;;,il7/~..... ,7.;'
M/NI -""'''pRRE/':
flies. no.l
.
rflED -
, t\._\~_
-'
Owner' ~""A... TIC.
Address \70 80-,<;
INFORMATION LINt. '1
726-3753
Sq. Ftg. t.lain
~q. Ftg. Access.
Sq. Ftg. Other
.-!lew__AddltAlter-"qep.
Fence Demo Change/Use
Other- -
oJ
I~-
10J
Construction Lender
-
Address
DESIGN TEAM
. (name)
Phone
(address)
(@xo;res)
(ohane no.l
Primary O""to.ie.li?
Structural t< '""V l-. Bar lCClTL G-
.
Electrical t..loo..1E. (t'>vJOoJr-.fl'
Mechanical (O...J....E.ll..)
CONTRACTORS (namel - ,
NO-. ~=...~_t'Cv .",.-
General U;",;t;>Qw '773AR..EP. ~L~
,
,~c ..1. r;>n~,,!''''
~~S"5~~)
(addrps~'
flir:c. M,,\
(pyrdl"pc,l
(n"/,\"~ PIn ,
GtAC.~ YS70 IN' //1:.2..
3"~81/;S
Plumbinp
Electrical O~"VI/ ~~<G:::.r I C'-'44&t1e.
"-1echani ca 1
f'l)- /as/
PLUI,lB I NG
ELECTRICAL
FEE I CHARGE ..lJ.l1
1 Residence of
SQ. FT.
1 New circuits alts.
V- or extensions
'fWd n.... .A.VJrc..
. SERVICES
MECHANICAL
NO.1
-----lEach single fixture
IRelocated building 1
(new fi.x. a~ditional)
IS.F.Residence I'
(l bath)
Duplex (1 bath) each"l
Additional bath I
Water service
Sewer
Temporary Construction
Change in existi~g
rl'ls-i~pncp .
multifamily, comm. or
Indu~trial
<<Ll..c.HARG.E. ..1lO.....1
~ .1 furnace/burner to..
BTU.' s!
. ;1./,
I Floor furnace r r j: )~
and vent' ' '. I
I~ 1S'!9 ' ,:
1 1 I Recessed wall
Sn~rp hp~tl'lr ~nrl vpnt
I I 1
1 1
I
:EL..cll8llliE..
Storm Sewer
....... NtIAJ Ct""... Dr",",,,
amps,
1 App 1 i ance vent
s@oarate
I ftationary evap.
cooler
1 V.ent fan with
sinole duct
1 Vent. system apart
. heatlM or A.C:
1 Mechanical exhaust
hood and durt
from
Wood stove/heater
f?eltJG...k. e,b~4.
3/22
TOTAL CHARGES
WHERE STATE LAH REQUIRES
shall not be val;; until the
3429
(dZ?
this pernit
I HAVE CAREFULLY EXAMINED the completed application for Dermit, and do hereby certify that all information hereon is true
and correct. and, I further certi fy tha t any and all work oerformed shall be done in accordance 1'1; th the Ordinances of the Ci ty
of Sor; ngfi e 1 d and the Laws of the S ta te of Ore1]on pe rta in; n9 to the work descri bed herei n. and tha t rw OCCUPAr~CY wi 11 be made
of any structure without the permission of the Building Division. 1 further certify that my registration with the Builder's
Board is in full force and effect as required by ORS 701.055,.that if exemot the basis for exemption is noted hereon. and that
only subcontractors, and employees who are.in comoliance with ORS 701.055 will be used on this Droject.
IW1E(please print) l?L.W100.ll:::;L~1L. SIGNATURE -I!4 '. iJ,~
FO~ OFFICE USE O~LY
Sq. Ftg. t1ain
Sq. Ft9. Access
Sq. Ftg. Other
DATE 10-17-7'1
Zone d.-II
Tyoe/Const. ~A(
. Bedrooms
Fire Zone R
Flood P1ain_N'IJ
Stories
I
Units
Occy Load
Occy Group 8-1-2..
x Va lue
,x Val ue
x Va 1 ue
TOTAL VALUATION 30, lZnelZ
BUILDING PERIIIT
Charges and
Surcharges
I Plan Ck. Co""'fInd
______lJ7.0t:J 65~/Blrlo Ppr Fp.
Plan Ck. Res
30~(Bldo Per Fee
PLUt~B ING PERMIT
Charges and
Surcharges
$oD rI
_n\_n~'~_
, .1:;"
_ ~__ _ u.15.fJ.!L
./,O
n_____.kerL
.,).
Fence
8.c. SS, Systems Development
Charae ,0, 5~) ,
1'::,' IC-n'~,
IIMJD
ELECTRICAL PERf1IT
Charges and
Surcharges
DOtOO
'Sidewa 1 k
A/C Paving
Total Comb. Permit
/10 7.~4
MECHANICAL PERMIT
, Charges and
Surcharges
TOTAL
IItJ 7.o~
Curb Cut
~J'
,1<_
.
t?t
,
~
-.::'~-
, . PERMIT VA[IDATtON
."J
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"
COM8INATION APPLICATION/PERMIT (CAP)
f,
I. Applicant to furnish
A. Job Address
B. legal Description
1. example- Tax lot 100,
17 03 43
2. example- lot 1. Block 3, 2~d A,ddition t,o'.
;prlngtield Estates' . " " " --,~
C, Name. etc. of owner and construction lender
'_ D. Energy Sources. .~-~ . , 1,._.. ,,I \.
1. examole- heat/electrical ceilinq/or forced air gas
2. exar1J.Ple- waterneater/electrlcal/or SOlar'
E. Square footage or valuation, etc. -
l. example- l250 sq. foot house, 500 sq. foot garage
2. example- if new project, check new.. i.f addition,
check add, etc. " .'
F. "-Building permit information: , ," "j . ,. ',,' ,:'
l. example - construct single family house with an .
attached garage
2. examele - remodel existing garage into family room
3, examJPle - convert single family residence into
restaurant (change of use)
G. Value of work as defined in Section,303'(a) of the
Structural Specialty Code' : I ,-",: , ,'.
H.' DESIGN TEAM 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
2. If the item(s) to be installed are not covered..on . ..
the abbreviated SChedules you should consul't theq, ' ,
fu 11 schedu I es
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. -
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 wnen the permit is issued.
" '
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Lane County Map Referen~~,.
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......-.........
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V. FOR OFFICE USE ONLY
Permit Clerk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
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','. . Perffii t app 1 i cantexE!nipf fro~" regi st:hti on with the Buil der I sJ'Sbarcj' be2iILfh;~
..Additional Project Informatio[l:
. ;' ~
.", , \
:.
PLANS REVIEWED BY:
name
Signature~~~~
'-
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,
,
t
,I
re
date //- ff-7?
1,'1.':""
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"'I'" ,,-' ,'.'e,~. :'. ".",\,' . '. . "'''.''''.''~.'~''''.' ''''i ' '~iF1EDII-\:?)--
[, :~.',..~ - ""l.I~-~~t'olO~', . ," -
.' ...','" .. ,.,,,.;'. . ,CITY Of SPRINGfiE~D, ,'. .,.", ,'..' IHfORt1ATlON UNt
j':f'~~~';~HON LINE,:;>.,;; ,<',";,.i..','r.F";''',~h'COMBINATlOH APPLICATlON/PERMIT"'Hi.\':'j);.:,,,', A 'f., ',. 726-3753
Job Address.3'fSS" aA'?".,e.wi~~1~ .~~~'~~;~~):'~'~~'~,i1:~J~~'C ~~: ~~~: ~~~:ss.
Legal oescriPtiOn'1.L.I2.{)i/.~.",~V.?, 7'::';O-;j~,Z2~Z.~':Jf,~J,~i,:,Water H~ater ' -SqNe~tgAd~~~~ ter_Rep.
Rang~'-EkG-' '. -'>'
'.' :-><-:'\ ,~;,:~~.:~~~~~~~tfi;;~'~;~~~t':~';*~,~~~~~:"4it~:, .. Fence Demo Change/Use
Owner A.'TL.""~T'C. R"~~~\;;L.t:>'~. ,':.':U,.,. .:: ~l;'~~:~:, Other--
, " '17 ' ,.... Build!no Pennit Info: Describe Work(i,.e.. 8uild Single
Address V'o 60-,(' 'Z~'541. rOR.TLA'-l~Phone"10~- Family nesidence \,ith Attached Garaoe)
. , ,....,:., ".', , \'~;';" '...,.: .-;-.....- ~YCM':l/DN C>~ V$H".D'~'~
Construction Lender- //1,; ~'S7: ~/~ S-"7/~+ 7.;
Addre;" <),:....:~:;;I!<~;'" Phone M/N/ -~"/RRET. ..
Ut:SiliN rI:.Ar1 . (name) (address) flies. no.) (exoires)
" ,
Primary";, O""'o-.ll!!.~
Structural
Electrical
t<....~ i=: Be.:;,lGen
....\o.....e. ( I">vJoJ. r=.fl ,
( 0 ""''''' 6. It')
Mechanical
CONTRACTORS (namel
NO", ;a.~,",I;:~'QV ,.,..-
General 7AAlZ7QoI..j ~.4-R..EA "=>~c.GS..
, ,
Plumbina
c",
234!; IJ. r;>".." 'RlZ.T''''''
(address)
f1i~~_ no_'
(pxr');rpc;,)
G~~ ~S/C W /I~
,
~1echanfcal
Electr;cal 01iJE~""/V t5c.t5cr , C(..4:,<ENe..
,
I
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.,s"3?1
I
l
I
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. .1 II ,'" ." ,ISSUANC, OF PFRrlIT" ~~
3q;;> I TOTAL CHARGES ,/500 TOTAL CHARGES r _", fo€i!O
that the Electrical work be done by an Electrical Contractor, the electrical portion of this permit
label has been signed by an Electrical Su~ervisor and returned to the Building Division .
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 tn. Laws of the State of Oregon oertaining to the work described herein, and that IIC OCCUPAllCY will be made
of any structure without the permission of the Building Division. I further certify that my registration with the Builder's
Board ;s in full force and effect as required by ORS 701.055, that if exemot the basis for exemption ;s noted hereon, and that
onl~ subcontractors and ~mP10y~eS who are in comoliance with OP.S mJ.055 ~n/;b~ u~on t~is ~roject., ,. <,,'::~' ,... "":.., ':.:
IW1E(Pleas.'print) ~.l.vJ'o.JI:>'L1!!.IL: ' ; SIr,;MTUREf~ :. /J,~' ":...'..'-.-D~~~ lo~'7-7"
FC~ OFFICE USE O~LY
Sq. Ftg. r1ain
Sq. Ftg. Access
Sq. Ftg. Other
PLur1B I NG
NO.
Each single fixture
Relocated building
(new fi,x. additional)
I' S.F. Residence
(J bath \
IDuPlex (1 bath) each
IAdditional bath
'Iwater service
,I Sewer
I Storm Sewer
.......1 New Cl"",.. D..,q./"
1
I
1
'~f' .
1
j
1
I
I
1
I
I
1
I
-I -
",..I,
. .
TOTAL CHARGES
WHERE STATE LAW REQUIRES
sha J 1 not be va 1 i oj unti 1 the
Zone C-J./
Fire Zone--1l'_
Flood Plain ltIn
Tyoe/Const, ~AI
Bedrooms
Stories
BUILDING PERMIT
Charges ..and
Surcharges
PLUI1B ING PERMIT
Charges and
Surcharges
ELECTRICAL PERrm
Charges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
FE>
I CHARGE
I
I
I
I
I
ELECTRICAL
. MECHANICAL
JJll......f
I Res,i dence of
SQ. FT.
'~ew circuits alts,
~ or extensions
wo l?~ AA/H'"
'I SERVICES
I lli-I.cIlAlllifJ_llll.....!
I furnace/burner to
'. 8TU.' s"
. '; I,
I Floor furnace ,it! '-;
and vent ,'...,':,:',:._
/f,-- 1S'!9
I 'I Recessed wall
. ~nArp h~~t~r Ann v~"t
I
Temporary Construction
/Change in existi~g
r~'S j qe.n~e .
Imultifamily, comm. or
Inrlu..trial
IOf
ICO~1,/IND. FEEDERS
I install/alter/relocate
ni(trih fppnpr(
IOf amp,,1
App 1 i ance vent
..~oaratp
Stationary evap.
cooler
Vent fan wi th
o::inale duct . ..,
Vent system apart from I
heatina or A.C.
I Mechanical exhaust
hood and durt
I \/ood stove/heater
.c
amps
f?eltJt;",k. ~,,~:'l!
Uni ts
Ocey Load
Occy GroupB-I-1..
~
~
~-
10J
(ohone no.)
28.@.-S34}
(nhonp on )
, 3'/':5-8//;:S
,?y ')- /&8/
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1:1
I I
II
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13122
I
I
JC' Value
x Va 1 ue
x ValuE'
, ," TOTAL VALUATICtI .30. fl':n!2!Z
Plan Ck. Comm/lnd
~5%/Bldo Ppr Fpp
Plan Ck. Res
lO%/Bldq Per F!e
F.ence~:
8<.5S
~ /c-n';79.
//J.OO
Systems Development
Charee t1.5~) ,
______iJ7.0El
SO~
~ 3.00
~l '.1:1. Domo
_~__:"__1S.fJ.P_ Sidewalk
, . (,0 I A/C Paving
___~_-:"~~gQ_ Curb Cut
.,;;.</ .
.' .... ..
. .',' '. ,..-,
, .~..
Total Comb. Pennit /10 7.tJ4
-- ----
.~,. -.. ~ .
TOTAL .. ,,;~.L~ ;:'. ' ;"/7 ,;;'/ '.'
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'COM8INATION APPLICATION/PERMIT (CAP) .. .,,.,'. .W
";,1>n",,,,;J "" "'.~"._.., ,,' ~' ~',,:,, '^, ,~...
''''~''. . ..,," .,,,.,..,; . ......~~t; ," ~ ..' ~..,,~ , "
1.,.Appllcant to furnlsh,.:f~'," . ,:';' ," r., '; ..,..,~ ,-
. A. Job Address ~~"t1;.-...:,:..~:~. "l.{;.~ ~ff,~; ."'''~''''... ,1.. I ~ ."
, f'... ~'"'~. ,~-, '~.;.. "'tt;.::' #~ . , ",
B,~ .LegaIOescription. '~;::<..l.'..,';-.'..o':-:"-~'" '_ ..... ___....
"~1.. 'example- Ta~ Lot 100, Lane County Map Reference. d,,'
'~:t~,17... 03 43 ..:,,~..,~2,-;,.;;.:''': ":'~...-;.': '-!, '.... ;Li....:'_~.... ~ _ i'~:- . .'.ct.
" '. . 2.. examele- Lot.1. Block ~, 2nd. Additi.gn to" '
J;~,_'i(,~~~~,springfield E~tates :"r .:."r\;:'~:"" :dC'-'....._..);' :____
~:~C. Name, etc, of , owner and construction lender '-
-,,'~.;)D.EnergYSources ..1';.",:"',., ., ,,'._.... ,J\.....
.:'-~:~,<,::,. 1. examele- heat/electrical ceilinq/or forced air oas
~'~"':~~;r~,~'. 2, examole- waterneater/electrlcal/or solar
: :~~.:E. Square footage or valuation. etc. -
,."f~'.:,,::..1., examele- @ sq. foot house. 500 sq. foot garage
~_....J'-.{J:-;;':"~. exam~le- if new project~ check new - iJ addition,
: . - "'/~' -. ,cneck add, etc. , '
'~j.:,,;::F...:' 8uilding pennit information: . .." ',:! ,.."
.." l' ".....1. example - construct single family house with an
. ~ ,~.;:::..... . ..attached garage
. '.';, , '2. 'exam~le - remodel existing garage into family room
'.. r\' "::."...,3. example. 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 ANO CONTRACTORS
,_.;'" ... To avoid design or construction delays, Building
'.'.,;' \ Oivision Staff must be able to contact appropriate
\. "/':";',-: ,,:. persons regarding design-information or jab site '. y/".
, 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. 80xes adjacent
,"" ,to the appropriate item(s) to be installed
B. Full Plumbin9, Mechanical. and Electrical Schedules
are available at the Building Oivision
l. To conserve space on the pennit fonn the schedules
have been abbreviated
2. If the item(s) to be installed are not covered ,on .
the abbreviated schedules you should consult the' ,.~
fu 11 schedu 1 es
C. 8UILOING OIVISION STAFF WILL FILL OUT ALL FEES ANO ,.. . ...,..
CHARGES ON THE SCHEOULES
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. Appl icant 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 pennit 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 woen the pennit is issued.
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V.. FOR OFFICE USE ONLY
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',~ PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPArlCY:
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~:'i~\:':".:"PERMIT VALIDAT'ioN
',\"..-
{y OF"SPRi NGF'IE'LD
~",..., -,- ... ".
No. B 52051()
\1'1..) \ L\ 19 fiG{' .. I
.om H\'ro ~ 1- \\ \ r\ f\\\.OJ ,,(~
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City Hall
Springfield, Oregan
Department ~I Public Wark'.
,OFFICIAL RECEIPT
FOr:'r1r\~. l(q0
~N\..Y)
I~q!>
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Received
'H 0'1 .01
~\~
AUTHOAIU:O SIG".ATUJU[
S"~LTO"'TUNN'ULL ""'''TEII' . I[UGE"r, Oil '''0'
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Permi t Cl erk-
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-,: Permi t app 1 i cant exempt' from reg i strati on with the Buil der 's' Board because:
Additional Project Information:
. ~~..
PLANS REVIEWED BY:
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