HomeMy WebLinkAboutPermit Building 1981-10-14 (2)
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1-1 WSPECTION LINE
726-3769
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Job Address
6/1 MIfIA/
CITY UF SPRINGFIELD
COfIBIilATION APPLICATION/PERMIT
E!IERr,y SOURCES:
Heat
t'Sa ter Hea ter
Ranqe
Lega 1 De~cri ption
INFORlIATION liNt II
726-3753
50, FIg, l'lain
~q. Ftg. Access.
Sq, Ftg, Other
New Add Alter Rep.
--Fence Oemo Change/Use
Other - -
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Build Single
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1<0
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Owner
C' 'i7JJ ,hi)? kJ.A/?
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J1D, )~/V <?I'!K --<(~~~;auPhone
Val'J5 of I-Iork: ,.
ff .;z 1l;;Z ~ --- .
Buiiciino Pennit Info: Describe Work(Le..
Familv nesidence With Attached Garaael
~Evf'v'y/F i'Y1Sr/A/r.;. Uk/A/
/lOOP", AJIf'/'A/JI p/pOA/r r/W/Jf-JY
O/tf!AJ9--CM..u;/fJ,. '7:<,t' 1(/J!1 CLA9; ''// "tfVOF
ellCS. no.) {exnires} (ohone no.
Address
Construction lender
Address
DES I oil TEAl.'
{name}
Phone
(address)
Primary
Structural
Electrical
Mechanical
CONTRACTORS
(name)
(address)
(lies. no.)
-::?B074 ('tf'OH/ A/J Et4!EA/c. '#"/905
'?44rJ;?I';.
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I ISSUANCE OF .FRlUT
TOTAL CHARGES I TOTAL CHARGES
that the Electrical work be done hy an 'Electrical Contractor, the electrical portinn of this permit
label has been signed by an'Electrical Supervisor and returned to the Building Division
General ,,1701=" ./r100F/;,vC /A/"{",
Plumbino
Electrical
~1echanical
PLUllBING
ELECTRICAL
NO.
FEF ...QJARr.F
Nn
FEF 1..cHAI!liE..Jlll.
Each single fixture
Residence of
SQ, FT.
Relocated building
(new fix, additionaI)
New circuits alts.
or extensions
S.F. Residence
(] bathl
Duplex (1 hath) each
IAdditional hath
I~ater service
Sewer
SERVICES
ITempOrary Cons~ruction
IChange in existing
r~'l j d..enc~
Imultifamily, COITll1. or
Tnrtustrial
Storm Sewer
IOf
ICOMN.IIND, FEEDERS
I Install/alter/relocate
di~trih. fppders
10f
amps.
amps.
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TOTAL CHARGES
WHERE STATE L~I-I REQUIRES
shall not be vali1 until the
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f/;
(ex!')ir~~l ." lohnn~ nn.
/t:?A-vY37,
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MECHANICAL
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_ ..E.ELILIJAR1i.. i
furnace/burner to
BTU's
/. ,
Floor furnace
and vent
\
Recessed wall
Sn~rp hp~tpr ~nrl vpnt
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Appliance vent
~eDarate
Stationary evap.
conler
I V'ent fan with
sinole duct
I Vent system apart from I
heatinc or A.C.
I Mechanical exhaust I
hood and duct
I ~~ood stove/heater I
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I HAVE CAREFUllY EXM1INED 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 the laws of the State of Oregon pertaining to the work described herein, and that NO 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 OP.S 7Ql.055 will be used on this project.
SIGiIATu~.6r/ A'u..--~
FO~ OFFICE ilSE O;/L Y
Sq, Ftg,
Sq, Ft9,
Sq, Ftg,
1lAf-IE(please print)/fOP A'tZ-'f'/A/t:: lA/C.
Zone
Fire Zone
Flood Plain
Tyoe/Const,
Bedrooms
Stories
Units
Occy Load
Occy Group
t1ain
Access
Other
BUILDING PERi-lIT
Charges an~
Surcharges
Plan Ck, Comm/lnd
65%/Bldo ~A~ ~pp
Plan Ck. Res
30%/Bldo Per F..
Fence
____n_.:l:.,'fA,'Q_
JIb
PLU'1BING PERMIT
Charges and
Surcha rges
O~o
I Sidewalk
I A/C Paving
I Curb Cut
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ELECTRICAL PERI~IT
Cha rges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
DATF /c.?h~/B'1
x
Value
Value
Value
x
x
TOT^L VALUATION
Syste~s Development
Charqe t1.5~)
,I
!Total
I
I TOTAL
Comb. rermi t
\
lI~if 91-:,
I. Applicant to furnish
A, Joh Address
B, Legal Oescription (
I. example- Tax Lot 100, Lane County Map Refer,
II 03 43
2, exa~le- Lot I, Block 3, 2nd Addition to.
~prlngtield Estates
C. Name. etc. of owner and construction lender
0, Energy Sources
1. examole- heat/electrical ceiling/or forced ~
2. example~ waterheater/electrical/or solar
E. Square footage or valuation, etc. -
I, examole- 1250 sq, foot house, 500 sq, foot n
2. example- if new project, check-new - if add1
chec~ add. etc. !"
F. Building permit information: .i
1. example - construct single family house ~it~
attached garage
2. examole - remodel existing garage into famil :00:
3. examole - convert single family residence in
res taurant (change of use) 1
G. Value of work as defined in Section 303 (a) of t
Structural Specialty Code "j
H, DESIGN TEM~ AND CONTRACTORS
To avoid design or construction delays. Building
~ivision Staff must be able to contact appropria
persons regarding design information or job site (
corrections, etc.
II. Abbreviated Plumbing, Mechanical, & Electrical Sched
A. Except where blank spaces occur in the descrjpti
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 Plumhing, Mechanical, and Electrical Schedu
are available at the Building Division ('
1. To conserve space on the permit form the sch l~ BY
ha ve been abbrev i a ted \, I
2, If the item(s) to be installed are not cover
the abbreviated schedules you should consult f.'
fu 11 schedu 1 es
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, ---
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 permit is issued for his
signa ture.
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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II I.
IV,
V, FOR OFFICE USE ONLY
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Springfield. Oregon .., ,---
Department of Public Work.
OFFICIAL RECEIPT
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No. B 5 7 4 7 5 .
19 RI .
Rec'd From 'nu...r. I? AI I-., "'_
Address ~lJ7'1 CJ~~; ~L
Dote
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Received For:
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Amount Received
<fl .;2.;f 9/-, - (
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AUTHORIZED SIGNATURE
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..."UO...TU"'''.ULL .."'NT".... "ucaN". 0" 17.0'
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Permit Clerk
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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:
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PLANS REVIEWED BY:
name
signature
,\
. L "... . .., ~ I
date
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