HomeMy WebLinkAboutPermit Building 1981-8-11
Job Address
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424- ft1"e;/~ Sr,
CITV OF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
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INFORMATION LINE
726-3753
INSPECTION LINE
726-3769
legal Description
ENERGY SOURCES:
Heat
Water Heater
RanJ:le
Value of Work:
Sq. ftg. Main
Sq. Ftg. Access.
Sq. ftg. Other
_New_Add_Alter_Rep.
_Fence_Dema_Change/Use
_Other
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I Own.",E~rArq I-X C, CL;9.;2~
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Building Permit Info: Describe Work (i.e., Build Single
Family Re~id~nce With Attached G~e)
l)/sco,<//l/c=c,7 ~ ~r /)"eA/',uS
Construction lender
Address
Phone
C:Ot<.lTRACTORS
(name)
(address)
(lies. no.) (expires) (phone no.)
~
(ljcs. no.) (expires) (phone na.\
DESIGN TEAM
(nome)
(address)
Primary
Structural
Electrical
Mechanical
General
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PlumbinA
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Electrical
Mechanical
PLUMBING
ELECTRICAL
MECHANICAL
NO. I
FEE
I CHARGE
NO. I
FEE
[CHARGE
NO. I
FEE
CHARGE
SERVICES
furnace/ burner to
~TU's
Appliance vent
separate
Stationary evap.
cooler
Vent fan with
single duct
Vent system apart from
heating or A.C.
Mechanical exhaust
hood and duct
Residence of
Each sin~le fixture
Relocated building
(new fix. additional)
S.f. Residence
(1 both)
s9. ft.
New circuits, alterations
or extensions
Duplex (1 both) each
Temporary Construction
Additional bath
Amps.
Water service
Sewer
Wood stove/heater
Storm Sewer
fEEDERS
Heat Puma
Air handler to
10.000 CFM
Air handler over
10.000 CFM
Amps.
ISSUANCE OF PERMIT
TOTAL CHARGES
AhkE
TOTAL CHARGES
TOTAL CHARGES
WHERE STATE LAW REQUIRES that th. ElectTical work be done by the Eledrical Contrador, the ehtctrical portion of this permit shall not be yalid until a
label has been signed by an Elemical Contractor and attached to the .Iedricol panel.
I HA VE CAREfUllY EXAMINED the completed application for permit, and do hereby certify that 011 information hereon is true and correct, and I further
certify that any and all work performed sholl be done in accordance with the Ordinances of the City of Springfield and the lows of the State of Oregon
pertaining to the work described herin, and that NO OCCUPANCY will be made of any structure without the permission of the Building .Dlvision. I further
certify that my registration with the Builder's Board is in full force and elffect as required by ORS 701.055, that if exempt the basis for exemption is noted
heron, and that only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project.
Basis for Builder's Board exemption:
NAME (pl.... Pdntl.4.e..GH-' E.
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'1GNAT~RE (.l!t ~.J ~ .AJ .' '~
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FOR OFFICE USE ONLY W
DATE %,il? /
x
Yalue
Value
Value
Zone Type/Canst. Units Sq. Fig. Main
Fire Zone Bedrooms n..cy Load Sq. Fig. Access
flood Plain ....tori... ('key Group Sq. ftg. Other
BUILDING PERMIT Plan Ck. Comm/lnd
Charge I and 65%IBldQ Per fee
Surcharges Plan Ck. Res
30%IBldq Per Fee
PLUMBING PERMIT
Charges and fence
Surcharges
o.m.
ELECTRICAL PERMIT
Charges and Sidewalk
Surcharges
AIC PavinQ
MECHA.NICAl PERMIT
Charges and Curb Cut
Surcharges --------
x
x
TOTAL VALUATION
Systems Development
Chorae 11.5%'
Total Comb. Permit
TOTAL
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COMBINATION APPLlCATlON/"- (C~:)
I. Applicant to furnish
Job Address
Legal Description
1. example-tax lot 100, Lane County Map Reference 17 03 43
2, example-Lot 1. Block 3, 2nd Addition to Springfield Estates
Name, etc. of owner and construction lender
Energy Sources
1. example-heat/electrical ceiling/or forced air gas"
2. example-water heater/electrical/or solar
Squa"re footage or valuation, etc.
1, example-1250 sq. foat house, 500 sq, foat garage
2. example-if new project, check new.if addition, check
add, etc,
F. Building perm'it information:
1. example-construct single family house with an attached
garage
2. example-remodel existing garage into family room
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. 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 abbrevi-
ated schedules you should consult the full schedules
C, BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
A,
B,
,
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C,
.' D.
E,
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III. Applicant to sign and date
.. Wheneyer possible, the initial appli~ation will be used as a
. >- worksheet only, Where possible, Building Division Staff wilL _~
'_i:.-~ . o' _ prepare a typew.riiten.copy and return it to the applicant at' .
,: the time the actual permit is issued for. his signature.
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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 .pFFICE USE ONLY
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PROJECT CONDITIONS TO BE SATISFIED' BEFORE OCCUPANCY:
Additional Project Information:
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PLANS REVIEWED BY,
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\PE~MIT VALlDATI~~
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Permit Cler~
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