HomeMy WebLinkAboutPermit Building 1981-10-14
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INFORlIATlON LIt,E .,
726-3753
So, Ftg, l'lain
~q. ~t9. Access.
Sq, FIg, Other
Ilew Add Alter Rep,
--Fence Oemo Change/Use
Other- -
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'; IllSPECTioll LlIIE
1726-3769
Job Address
6/1 MIf/A/
CITY OF SPRIIIGFIELO
COMBJ:IATlON APPLICATlON/PERMIT
I E,IERr,y SOURCES:
Heat
Hater Heater
Legal Description
Owner
l7-o':1-B5-81 D 9;L6-t)
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)fD, A/V C(/?I( --1~",:-Co/'~Phone
Ranqe
Address
OE> IGIl TEAll
(name)
Phone
(address)
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Build Single '"
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!fC'OP", AJI3'/A/)( r/tOA/r rAAJoJJY' ~
.fJ/I1BJP>-(M,()/)/hc ?~;, If!M eLI/lit; ''A "(1'001"._
(lie5. no.) (exoires) (ohone no.
Val'J5 of Hork:
-ff ~ fj';2 :.3 ---
Buildino Permit Info: Describe Work{Le.,
Familv nesidence l'lith .A.ttached r.araae)
Address
/P.EA'OI'/ F
.t: Y/Sr/A/(c
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Construction Lender
Primary
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Structural
Electrical
Mechanical
CONTRACTORS
(name)
(address)
11 ieo;,. no_)
(exoires) }ohone no.)
/ t?/:<</~,
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74-4()71Cl
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General AJo,t::: J,70CF/A/C /A/{;
::;J flt!74 {'t!'ClJ(/ A/J cz,1<'EAJe '#/'/0;;
Pl umbi no
Electrical
~1echanical
i
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PLUIIBIIIG
ELECTRICAL
MECHANICAL '
Each single fixture
FEE CHARGE 'Jll ... r"'IRG.E. ..HQ...1
Residence of furnace/burner.to
5Q, FT, BTU's
... r"'llllif. I
NO.
Relocated building
(new fix, addiLional)
Storm Sewer
amps.l
I
IInstall/alter/relocate /
rli~trih_ f~prlpr~
IOf amps./ I
1 I
1 I
1 I ISSUANCE OF PFRI1lT
TOTAL CHARGES I TOTAL CHARGES
that the Electrical work be done by an Electrical Contractor, the electrical portion of this pernit
label has been signed by an Electrical Supervisor and returned to the Building Division
Of
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Floor furnace
and vent
I' Recessed wall
, SOi'll':P h~tltp,. orlnd vPl't
New circuits alts.
or extensions
S.F. Residence
(I bath)
Ouplex (I bath) each
I SERV'rCES
I
COMfl,/INO, FEEOERS
I App 1 i ance vent
SPDi\l"i'ltP.
I S'tat.ionary evap.
cooler
I Vent fan wi th
sinole duct
Vent system apart from I
heatina or A.C.
Mechanical exhaust
hood and duct
Il100d stove/heater
I
1
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1
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1
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1
Additional bath
IWa tel" servi ce
I Sewer
ITempOrary Construction
IChange in existing
I"P~jq~f1cP
Imultifamily, comm. or
Tnnus.tri"l
TOTAL CHARGES
WHERE STATE L~W REQUIRES
shall not be vali1 until the
I HAVE CAREFULLY EXNlIlIEO the completed application for permit, and do herehy certify that all infonnation 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 the laws of the State of Oregon pertaining to the work described herein, and that UO OCCUPArKY 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 OP.S 7nl.055 will be used on this project.
1IA1.1E(please print)1l0P A'CI;;e:/,1h;' JA/C.
SIGrlATUR~.hI'/ ~~
, -
FOr. OfFICEilSE Q;ILY
OAT.E h/i<'//B'/
Zone
Fi re Zone
Flood Plain
Tvoe/Const,
Bedrooms
S tori es
Units
Occy Load
Occ'y Group
Sn, Ftg, 11ain
Sq. rtg, Access
Sq, Ftg, Other
x
x
Value
Value
Value
x
TOTAL VALUATION
BUILDING PERmT
Charges an~
Surcharges
____n_~tQ-L
JIb
Plan Ck, Comm/Ind
65%/Bld~ p~r Fpp
Plan Ck. Res
3Dt/Bldo Per Fe.
Systems Development
Charoe O.5~)
PLU/~BING PERMIT
Cha rges and
Surcharges
Fence
------------1 Demo
I Sidewalk
------------
I A/C Paving
Curh Cut
jrotal Comb. rermit
I
I TOTAL
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IIdlif 9/)
ELECTRICAL PERI~IT
Cha rges and
Surcharges
MECHANICAL PERMIT
Cha rges and
Surcharges
I. Applicant to furnish
A. Job Address
B. legal Description
I, example- Tax Lot 100, Lane County Map Refer,
11 UJ 43
2, exa~le~ Lot I, Block 3, 2nd Addition ~o
~prlngtleld Estates
C. Name. etc. of owner and construction lender
0, Energy Sources
I. exam~le- heat/electrical ceilinqfor forced,
2. examole- waterheater/electrical/or solar
E. Square- footage or valuation, etc. ------
I, examole- 1250 sq, foot house, 500 sq, foot 9
2. example- if new project, c~eck-new - if add;
cneck add. etc.
F. Building permit information: -i
1. example - construct single family house wit~
attached garage .'
2. examole - remodel existing garage into famil ;00:
3. examole - convert single family residenc~ in
restaurant (change of use) ~
G. Value of work as defined in Section 303 (a) of t
Structural Specialty Code '1
H, DESIGN TEN~ AND CONTRACTORS
To avoid design or construction delays, Building
Division Staff must be able to contact appropria
persons regarding design information or job site (
corrections, etc.
II. Abbreviated Plumbing, Mechanical, & Electrical Sthed
A. Except where blank spaces occur in the descripti
portion of the Mechanical and Electrical Schedul
the applicant need fill-in only the No. Boxes ad
to the appropriate item(s) to he installed'
B. Full Plumbing, Mechanical, and Electrir.al Schedu
are available at the Building Division
1. To conserve space on the permit form the sch I,...
have been abbreviated
2, If the item(s) to be installed are not cover
the ahbreviated schedules you should consult ~...'
full schedules
C. BUILDING DIVISION STAFF WILL FILL OU., ALL FEES At-
CHARGES ON THE SCHEDULES
0, 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 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 when the permit is. issued.
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COMBINATION APPLICATION/PERMIT (CAP)
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V, FOR OFFICE USE ONLY
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Springfield, Oregon _./' ,'- "
Deportmant of Public Work.
OFFICIAL RECEIPT
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No. B5 7 4 7 5 .
/0-19 199;1 .
( Rec'd From ~_ I?~ .
Address J.tn4 Cn-l.n') ~L _ f
Date
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Received Far:
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AUTHOllllillO 51GIoIATUIIIE
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."ILTO".TU"".ULL ~"I"TIl". . IlUOIl"Il. 0" .T.O'
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Pennit Clerk
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
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PLANS REVIEWED BY:
name
signature
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date
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