HomeMy WebLinkAboutPermit Building 1983-4-4
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I INSPECTION LINE. CITY U, SPRINGFIELD
726-3769 CmmIIIATlON APPLICATION/PERMIT
Job Add ss ,- JL A. 7- ):f VI I ElIERGY SOURCES:
re .7 /2 /Ix:r.)f 02:; P Heat
Legal De,cription \'1 (')~ W 0 Z ~ l'later Heater
~ . i Range
V'j)u, of Hork:
OwnerjJtJA/ ,)~A/ES .zt'1;2..."7I'---
Phone lfuihiino Permit Info: Oeser,be Work(i~e"
Address PoOr ~ '7B'/'< Familv Residence Hith Attached Gar~a~\
INFORIIATlON liNt
726-3753
Sq. Ftg. 1.la i n
~q. Ftg. Access.
Sq. Ftg. Other
Ilew Add Alter Pep.
-Fence Demo Change/Use
Other- -
;;/,/6-,$' JI/ E.
Construction Lender
C?-j 74{) (
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Build Single
Address
DESIGN TEAI~
(name)
Phone
(address)
(lies. no.)
(exoires)
(ohone no.
Primary
Structural
Electrical
Mechanical
CONTRACTORS
(name)
(address)
!lies. no.)
(exnil"'ps)
(ohone no.l
Genera 1
/to F I1er?PJA/r;.!.JLC..
;2.!S()74UoW /1-1 ~"II/? ~/er3
'"?440.269'
Plumbino
Electrical
~lechanical
PLUIIBltlG
ELECTRICAL
MECHANICAL
-1!!h
FFF rHARGF 'IP
... rH'IRG.E. ..l!ll....
H~ r~ARG.E..
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
5.F. Residence
(l bath)
Duplex (1 bath) each
Additional bath
SERVICES
Recessed wall
Sn~~p hp~tpr ~nrl vpnt
Storm Sewer
Of
amps.
Appliance vent
seoarate
ftationary evap.
cooler
Vent fan with
sinole duct
Vent system apart from
hea ti no or A. C.
Mechanical exhaust
hood and duct
Wood stove/heater
~Ia ter servi ce
Temporary Construction
Change in existing
res j rly.nee
multifamily, comm. or
Industri~l
Sewer
CO~~./IND. FEEDERS
Install/alter/relocate
distrib. fe~ders
Of
a:mps.
ISSUANC, OF PFRr1IT
TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES
. WHERE STATE L."~ REQUIRES that the Electrical work be done by an,'Electrical Contractor, the electrical portion of this permit
shall not be val;~ until the label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXAMINED the completed application for permit, and do hereby certify that all information hereon 1s true
and correct, and 1 further certify that any and 1'111 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 OCCUPAUCY 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 7nl.055 will be used on this project.
NAI'IE(please print) JtlICIfJl:eL ,1'0 Y /{t)P
SIGNATUR~~""'/A"~ .//~
DATE~/ .G"='r
Zone
Fire Zone
Flood Plain
Tvpe/Const.
Bedrooms
Stories
Units
Occy Load
Occy Group
-
FOR OFFICE USE OI~LY
Sq. Ftg. Ila1n
Sq. Ftg. Access
Sq. Ftg. Other
x
Value
Value
Value
x
x
TOTAL VALUATION
BUILDING PERNlT
Charges and
Surcharges
_ ~ Plan Ck. Comm/Ind
____~~..:~9___~/Blda p.Pr Fpp
" f.l Plan Ck. Res
C>' . U'tJ 30%/BldQ Per Fee
Fence
Systems Development
Charoe (1.5~) .
PLur~BING PERMIT
Charges and
Surcharges
D~R1o
ELECTR ICAL PERI:IT 'S1 dewa I k
Charges and ------------
SurCharges A/C Paving
Total Comb. Permit
TOTAL
. ! 6' <;.0 g' .~
/IECHANICAL PERMIT
Charges and
Surcharges
Curb Cut
r
.
,
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. examole- Lot I. Block 3, 2nd Addition to
~pr'ngt;eld Estates
C. Name. etc. of owner and construction lender
O. Energy Sources
1. example- heat/electrical ce;l;~Q/or forced air Qas
2. example. waterheater/electr;cal/or solar
E. Square footage or valuation, etc. -
1. examole- 1250 sq. foot house, 500 sq. .foot garage
2. example- if new project. checknew'. if addition,
chec k add, etc.
F. Building pennit information:
1. example - construct single family house with an
a ttached garage
2. example - 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. 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
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.
V. FOR OFFICE USE ONLY
Pennit Cl erk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Infonnation:
PLANS REVIEWEO BY:
name
'"
signature
date
,
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