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Home My WebLink AboutPermit Building 2007-03-21Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-37 69 Inspection Line Building/C ombination Permit PERMIT NO: COM2007 -00125ISSUED: 0312112007APPLIEDz 0l/2512007 EXPIRES: 0912112007VALUE: $ 46,968.00 SITE ADDRESS: 66 SHADY LP ASSESSOR'SPARCELNO.: 1703262300608 Springfield PROJECT DESCRIPTION: Addition to existing single family residence TYPE OF WORK: Single Family Residence TYPE OF USE: Addition Residential PhoneNumber: 541-744-3825 License Expiration Date Phone Owner: Address: Contractor Type Electrical Mechanical VINCENT CRAWFORI) 66 SHADY LOOP SPRINGFIELD OR 97477 Contractor OWNER OWNER OWNER he Oregcn Utif ry CONTRACTOR INFORMATION # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: Frontyard Setback: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Improvements: Storm Sewer Available: Special Instruction: R-3 VB Water Type: Range Type: Energy Path: Sprinkled Building; LoiSizer Sq Ftlst Efqor: Sq Ft)nd Fl6or: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: 456 Path I nla REQUIRED PARKING 7.30 25.00 9.00 o"eruffiSdERMii SHArr EXPIRE tF THE WOBK # StTCCtIfFbBBtsTD UNI]ER THIS PERM11 ;SMIiCANNCd:naved,sffiffiED 0R ts ABANDoNED Fgfio.F".,'zo or ffi fo,v66"6fiv pER r oD Sidewalk Type: Downspouts/Drains: Notes: Some bldg envelope over existing impervious area. SDC's only include new impervious area fees.JLP 2127107 PUBLIC IMPROVEMENTS Page I of3 Al lt-rr' , ' follow rult Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676Fax 541-7 26-37 69 Inspection Line Building/Combination Permit PERMIT NO: COM2007 -00125ISSUED: 0312112007APPLIED: 0112512007 EXPIRESz 0912112007VALUE: $ 46,968.00 Description Dwellings Type of Construction V Wood Frame $ Per Sq Ft Square Footage or multiplier or Bid Amount $103.00 456.00 Total Value of Project Amount Paid Date Paid Value $46,968.00 $46,968.00 Date Calculated 0u2512007 Fee Description Plan Review Residential + l0o/o Administrative Fee + 57o Technology Fee + 87o State Surcharge Add, Alter, Extend Circ Add, Alter, Extend Circ Ea Add Building Permit Fire SF Fee - Residential Fixture Minimum/Adj ustment Mechanical Miscellaneous Mechanical Plan Review Minor - Planning Sanitary Sewer - Improvement Sanitary Sewer - Reimbursement SDC Sanitary/Storm Admin Storm Drainage Impervious Area Storm Sewer - lst 50 Feet Vent Fan Total Amount Paid Receipt Number 2200700000000000109 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 320070000000000016r 320070000000000016r 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 3200700000000000161 $229.52 $58.49 $33.71 s44.97 $43.00 $6.00 $353.10 $22.80 $70.00 $27.00 $12.00 $112.00 $197.91 s260.27 $28.31 $108.07 $45.00 $6.00 $1,658.15 u2st07 3t2u07 3t2u07 3t2u07 3t2U07 312u07 3t2u07 3tzu07 3t2u07 3tzu07 312u07 3tzu07 3t2U07 3t2U07 3t21t07 3t2u07 3t2U07 3t2U07 Fops Pqid Plan Reviews Initial Review Plannins Review Public Works Review Public Works Review 0u3012007 02t02t2007 02/02t2007 02t02t2007 03n6t2007 02t0212007 APP APP WI LLH TAJ JLP 02t28t2007 02t27t2007 APP JLP APP DLM Rcv d 2 12 12007--Waiting in order PW rcvd for rvw.JLP Some bldg envelope over existing impervious area. SDC's only include new impervious area fees.JLP 2t27t07 Sent request for information to applicant 2l28l07dlm. Met w/ Mr. Lewis to explain requested info. 3 12107 dlm, Received requested info. 316/07dlm. Structural Review 02t02t2007 03t08t2007 Paee 2 of3 Valuation Descriotion I Status Issued 225 Fifth Streeto Springfield, OR 541-726-3753 Phone 541-726-3676 Ftx 541 -7 26-37 69 Inspection Line Building/Combination Permit PERMIT NO: COM2007 -00125ISSUED: 0312112007APPLIED: 0112512007 EXPIREST 0912112007VALUE: $ 46,968.00 To Request an inspection call the 24 hour recording at 726-3769. All inspections requested before 7:00 a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following work day. Footing: After trenches are excavated. Foundation: After forms are erected but prior to concrete placement. Post and Beam: Prior to floor insulation or decking. Floor Insulation: Prior to decking. Framing Inspection: Prior to cover and after all rough in inspections have been approved. Wall Insulation: Prior to cover. Ceiling Insulation: Prior to cover. Final Building: After all required inspections have been requested and approved and the building is complete. Underfloor Plumbing: Prior to insulation or decking. Underfloor Drain: Prior to cover or placement of concrete. Rough Plumbing: Prior to cover and including required testing. Storm Sewer Line: Prior to filling trench. Final Plumbing: When all plumbing work is complete. Rough Mechanical: Prior to Cover Final Mechanical: When all mechanical work is complete. Rough Electric: Prior to Cover Final Electric: When all electrical work is complete. By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and I further certify that any and all work performed 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 OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during o < 2l-o > Owner or Contractors Page 3 of3 Date I Keourreo lnsDecuons I Construction Contractors Board Permit #:COnaL<>o , aOtZ{ 700 Summer St llE Suite 300 PO Box 14140 Salem OR 97309-5052 Phone: 503-3784621 Web Address: www.ccb.state.or.us 66 *L/Address: Issued l. I own, reside in, or will reside in the completed structure. Date: Statement: lnformation Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign thefollowing statement before a building permit can be issued. This statement is requiredfor residential building, electrical, mechanical and plumbing permits. Ltcensed architect and engineer applicants, exemptfrom licensing under ORS 701.010(7), need not submit this statement. This statement will befiled with the permit. A h-2. I understand that I must become licensed as a construction contractor if the structure is sold or offered for sale before or on completion. tr 3A. My general contractor is (Name)(ccB #) I will instruct my general conhactor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR 38. I will be my own general contractor. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will contract with a contractor who is licensed with the CCB and will immediately notiff the office issuing this building permit of the name of the contractor. I hereby certify that the above information is correct and that I have read and do understand the Information Notice to Property Owners about Construction Responsibilities on the reverse side of this form. .- 2s^-a of :)@ate) (White copy to issuing agency permitfile, pink copy to applicant.) Property_owner.doc 06-0 I -04 Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 38: Actimg e$ hur Own Gexrerat Cb'ntraetor? *NTSRT*AYISN ruOTICH T& PM*PHRTY SWNERS AE*t,? *SN$TRU*YIff f'l RX$PON$IB|LIT*E$ flIOIS: This lnf*rrnation f,latic*ta Pr*p*rty Olvners a&o*f Sonsfru;ofion &esp*nslbilifies was develaped bythe S*nsfrrc#sn eonfra*fcrs S*ard i* accardanc* witlt ORS 70?.S$$(5J, p*ssed hy the ?989 Sregon lagislafire. 1f y*u ar* *ctixg es y*$r *l*x c*i:tr**t*r t* c*nstruet e $sw hom* *r rxal<* a substantixl irxpr*vernent t* an existing struetw*, ):,*$ {an pr*vent many problems hy being aware of the f*llowing respcnsibi}ities and s*neerx?s. &xaplelyex" Kespoxr*ibiXit{*s Yo11 will, in m*lst instances, he rul*d t* be ax o'enlptroyetr" s:rd the cor:traet*rs you c<ltkact witli will be "gmploy*e*" if yq}u u$e e$&trai:rors nr:rt lisensed ixrith the Construetion C*ntriaet*rs llclard t* d* Iab*r in ccnstrxeting *r t* assist in the **$struct{*n er irnpr*ve*:r::t of,a resiifer:tia} sku*ture. &s tks *mgr}oyer, you must coxrpty witk tfue f*}lcwing; $r*g*x's W*€kh*lding YxN X,aw: As an employer, you rnust vrithhold tncome {axcs from empi*yee wage$ at the time *r,rp}*yees *r* p*id. Y*u wtll h* triable fq:r th.s tas :iey:"l":en{$ *v*n if y*u donx't a*tual}y witi*iold the tax fr*m yner *mptr*y***" F*r:xor* inf*nx*ti*n, caltr the X}*parhnent q:f Rev*n*s at 5*3-378d9SS. Un**rpl<lyxaent Xms&ram*e Tnx: As *x *xlpi*yer, yclu a.re r*q*ir*d t* pay * tim f,or unemploymeflt in$r:r*ncs purposss cn the w&g*$ *f aII *:npi*yees. }i*r mE:re ixfi:m*ti*n, eal1 th* *reg*:"r fimptr*ymen{ i}cpar*n*rt *t 5S}-94?-1488. The Oregon $usin*ss {<1entificati*n Numh*r (BIN} is *r e*mbined nffi::b*r Snr both (hegon Withhnlding and Uxemp1*3xre*t{n*ura*e*Tax"Y*fi,le{tlraBXN,eatr}5*3-*45-8s9lorf,olthe appropriat* f*ms. W'orkers' Compensati*n Ins*ranee: As an ernployer, you are subject to the Oregon Vy'orkers' Compensation Law, ard must obtain workers' cornpensalion insurance for y**r employees. If yox fail to obtain workers'cornpensation i*srranee, you cculd be subject to penalties afld be liable f'or all clairn costs if one afyor:r emplcyees is injured sn the job. Far rncre inforrnation, call tho W'orkers' Cornpensation Division at the f)epartmsnt af Conslrmer and Business Sen ices at 5*3-94?*7815. U.$, Xxrt*rna! I*.evcnx* $*rvice; As *n *rxg:k:y*r, you r::xst rpithh*ld lbrJeral income tax fram employees' $rages"." Y*u wiil he iiable tirr $he l*x pa3nxent even if y*a di&r't actually e*ithhold the t*lx" *Icr a F*derxi EIld nur::ber, eall the IR"S af t-1300-{t29-4933 m visit tir*ir web site at -\y1rt&19$.gsv. $thcr KospmxsibfiIit$es &nd Arsas cf C*n*&rns C*d* C*:xxpliam**:: As *h* per:xit &*trd*r f?:r tbl* pr*l3ect, yttrl &re resp*:r"Lsi1:k f*r resoh'ir:g axy f*ilxre t* rneet c*d* r*q*irernents that m:ay be br**g?:t to y*Llr atte*lion Nhr*xgh insp*ctic*s. LinfuiXity axd Property flxrxlage }xs*r*uee: Cr:ntaet y*u;" ir:sur*nee ag*nt to see if y*u have adequa!* insurarice eov*reg{: lbr a**i*}*rrls and *mis*i*ns xu*k as *b}li*g t**.ls, paint {,}ver $pray} w;rter q}ar**ge fr*m pipre pu*ctures, {it* *r work that must be red*ne" Time: Make sure you have sufficient time to sup*rvise ycur employee*. Xxper*ise: Make sure y*u *rave the skjlls to act as your own gcneral eonkaetor, to coordinate the workof rough-in and frnish kades, and t* n*lifu buil*ii*g o*{icials *s tbe appropriate times sa th*y cax p*rfonn the required inspectio*e. If you hav* additional questi*ns e*}I th* C*nstn**ti*n C*:xtract*rs }3*ar<1 {5{:}3-37$-462i} or wrjt* the agency at }CI 3ox 1414'0, Salern, fiR 973*9-5052. Property_*wner.d*c 06-0 i -04 SPRINGFTELE .'" ,.. ,tt,,., efi, . ZON INITIALS DATE 225FIFTHSTREEToSPRINCFIELD,OR9T4TTTPH:(541)72G3?53'FAX:(541)726-3589 SOURCE ELECTRICAL Itrs""TION Date 3l Lt lkrolCiry Job Number t 06 LEGAL A. Nen'llesidential - Siugle or N'Iulti-Familv per dwelling unit' JOB DESCRIPTION , /,aA Permits are non-transferable and expire if work is not started within 180 days of issuance or if work is Suspended for 180 daYs. I COf,TIT,A C T O R IN STALLA fl ON ONZ }' Electrical Contractor Address City Phone Supervisor License N Expiration Date Constr umber Service Included 1000 sq. ft. or less $ 106'00 Each additional500 sq' ft. or portion thereof $ 19.00 Each Manufact'd Home or Modular Dwelling Service or $50.00 leeoer B. Services or Feeders - Installation, Alterations or Relocation: 200 Amps or less 201 Amps to 400 AmPs 401 Amps to 600 AmPs 601 Amps to 1000 AmPs Over 1000 AmPs/Volts Reconnect OnlY C. TemporarY Services or Feeders $ 63.00 $ 7*5..00 - 's125.00 $ 163.00 $375.00 $ 50'00 Date Inst$Sffifiteration ol T":"""31',?l II IHr- zoo {pggflgMlT SHAt-t- tlf *'l."nn'f iiltffi#f;ffiffiH'TJ-Ti#-'ljt o""' K{+ffi S Aq@ EePEee "8" above' D- Bridch Circuits New Alteration or-Extension Per Panel WORK ff{q' 69-00 lbt.oo Signanrre of Supervising Electrician owners Name Vr,G ar,tfiir OneCircuit I $43'00 Each Additional Circuit or with i.*1." or Feeder Permit I S 3'oo 43:") 6) E. N,Iiscellaneous (service/feeder not included) -Each Installation s s0.00 $ 50.00 $ 25.00 $ 45.00 LE Address A City #-,gQ.' ' Pnon" gl:)44'3t2-f OWNER INSTALLATION The installation is being made on properly I own which is not intended for sale, lease or rent.Minimum Electric Permit lnspection Fee is $45'00 + S P4. SWTOTAL OF ABOVE 8% State Surcharge l0% Administrative Fee 5% TechnologY Fee o,3) Pump or irrigation Sign/Outline Lighting Limited EnergY/Residential Limited EnergY/Commercial ( Inspection Request: 726'37 69 TOTAL Shared Drive(T:/Building Forms/Etectrical Permit Application 846'doc d DRAINAGE FD(TI.]RE UNIT CALCT]LATION TABLE NUMBER OF NEW FXTURES X UNTT EQUTVALENT: DRAINAGE FDffURE I'INTTS FOR CAICLITATE ONLY THE NET ADDMONAL NO. OF FD(TLIRES UNIT FXTI]RE TYPE NEW OLD ALENT MISCELLANEOUS DFU T\?E NUMBER OF EDU'S TOTAL DRAINAGE FD(TI]RE I]NITS lsa toa unit set at 167 MWMC CREDIT CALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE DRAINAGE FD(TTIRE UMTS 0 2 1979 *EDU BEFORE 1979 $5.29 $5.19 $5.12 $4.98 $4.80 $4.63 $4.40 $4.07 $3.67 $3.22 $2.73 $2.25 $1.80 IS LAND ELGIBLE FOR ANNEXATION CREDIT? @nter 1 for Yes, 2 for No) IS IMPROVEMENT ELGIBLE FOR ANNEX. CREDIT? (Enter I for Yes, 2 for No) BASE YEAR CREDIT FOR LAND (IF 2 1980 1983 r979 I 981 1987 1984 1985 I 986 1987 1988 I 989 1990 1991 1992 t993 1994 1995 t996 1997 1998 1999 VALUE / IOOO $0.00 CREDITRATE $5.29x CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALTIE / IOOO CREDIT RATE $0.00 x $5.29 TOTALMWMC CREDTT$1.59 $1.45 $1.25 $1.09 $0.92 $o.72 $0.48 $0.28 $0.09 $0;05 3103BAT}IUB 1 000DRINKING FOI.INTAIN 0 3 00FLOORDRAIN 0030INTERCEPTORS FOR GREASE / OIL / SOLIDS /ETC. 6 000INTERCEPTORS FOR SAND /AI-TTO WASH i ETC. 0 2 00LAI}NDRY TI-IB 0030CLOTTIESWASTIER / MOP SINK 6 000CLoTHESWASHER- 3 ORMORE (EA) 00120MOBILE HOME PARK TRAP (I PER TRAILER) 0001RECEPTOR FOR REFRIG / WATER STATION / ETC. 3 000RECEPTORFOR COM. SINK / DsHWASHER / ETC. 2021SHOWER. SINGLE STALL 2 000SHOWE& GANG (NLIIvIBER OF HEIADJ) 0 3 00SINK:COMMERCIAL/RESIDENTIAL KITCHEN 0020SINK: COMMERCIAL BAR 2 210SINK: WASH BASIN/DOI.]BLE LAVATORY 0 1 00BARSINK: SINGLE LAVATORY/RESIDENTTAL 0050URINAL. STALL IW/J,L 6 000TOILET, PIIBLIC INSTALLATION 0 3 31TOILET. PRTVATE INSTALLATION 10 YEAR ANNEXED CREDIT RATE/$I,OOO ASSESSED VALUE 2000 200t 20 JOURNAL ORJOB NTIMBER: NAME OR COMPANY: LOCATION: TAX LOTNI.MBER: DEVELOPMENT TYPE: NEWDWELLING TINITS CITY OF S coM2007-00125 Vincent Crawford 66 1703262300608 SINGLE FAMILY RESIDENCE COST PER S.F $0.336 SYSTEMS DEVELOPMENT VS-RKSHEET 00 I. STORM DRAINAGE DIRECT RLINOFF TO CITY STORM SYSTEM BUTLDTNG SZE (SF) 0 LOT SZE (SF): C}IARGE $108.07 IMPERVIOUS S.F. x 322.00 RT]NOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CIry STANDARDS IMPERVIOUS S.F 0.00 NLIMBER OF DFU's l0 B. IMPROVEMENT COST: NUMBER OF DFU's 10 B. IMPROVEMENT COST: ADT TRIP RATE 9.57 SUBTOTAL s565.24 COST PER S.F s0.336 COST PER DFU $26.03 $ 19.79 NTIMBEROF I.INITS 0 NUMBER OF UNITS 0 ADM. FEERATE 5o/o DISCOI.INTRATE 50o/o $108.07 DISCOLTNT $0.00 x x x x x x x x ITEM 1 TOTAL - STORM DRAINAGE SDC 2. SANITARY SEWER. CITY A REIMBT'RSEMENT COST: A. ITEM 2 TOTAL - CITY SANTTARY SEWER SDC 3. TRANSPORTATION COST: $458.17 COST PER TRIP $19.81 COST PER TRIP $87.39 $0.00 xx NEW TRIPFACTOR 1.00 NEW TRIP FACTOR 1.00 xx ITEM 3 TOTAL - TRANSPORTATION SDC 4. SANITARY SEWER - MWMC A REIMBURSEMENT COST: NTiMBEROFFEU's 0 B. IMPROVEMENT COST: NUMBER OF FEU's 0 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMIMSTRATTVE FEE ITEM 4 TOTAL - MWMC SANITARY SEWER SDC SUBTOTAL (ADD ITEMS I,2,3, & 4) 5. ADMIMSTRATIVE FEE: $0-00 $s66.24 CHARGE s28.31 TOTAL SANITARY ADMIMSTRATION FEE: TOTAL TRANSPORTATION ADMIMSTRATION FEE: Jeff Prociw 2/28/2007 ADT TRIP RATE 9.57 $108.07 $260.27 $197.91 $0.00 $0.00 $0.00 $0.00 $594.55 1070 1091 t092 I 093 1094 1055 1056 1079 I 078 V)HooU HFa o lJt& COST PER FEU $91.61 COST PER FEU $961.s2 PRMAREDBY DATE TOTAL SDC CHARGES x 225 Fifth Street Springfield, Oregon 97 477 541-726-3759 Phone Ciru of Springfield Official Receipt L elopment Services Department Public Works Department RECEIPT#: 3200700000000000161 Date: 0312112007 l:ll:4ePM Job/Journal Number coM2007-00125 coM'2007-0012s coM2007-00125 coM2007-0012s coM2007-00125 coM2007-00125 coM2007-00125 coM2007-00125 coM2007-00125 coM2007-00125 colll2007-0012s coM2007-00125 coM2007-00125 coM2007-00125 coM2007-0012s coM2007-0012s coM2007-00125 Description Fire SF Fee - Residential Storm Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Sanitary/Storm Admin Building Permit Fixture Storm Sewer - lst 50 Feet Vent Fan Miscellaneous Mechanical Minimum/Adjustrnent Mechanical Add, Alter, Extend Circ Add, Alter, Extend Circ Ea Add + 8% State Surcharge + lUYo Administrative Fee Plan Review Minor - Planning + 5%o Technology Fee Item Total:$1,428.63 Type of Payment Paid By Received By Batch Number Number How Received Amount Paid Amount Due 22.80 108.07 260.27 197.91 28.3r 353.10 70.00 45.00 6.00 12.00 27.00 43.00 6.00 44.97 58.49 112.00 33.71 CreditCard VINCE CRAWFORD nJm 015058 In Person Payment Total: $1,428.63 -i728it cReceintl Page I of I 3t2112007 GITY OF SPRT,.GFIELD SYSTEMS DEVELOPMENT ] .KSHEET JO{.IRNAL OR JOB NUMBER: NAME OR COMPA}.IY: LOCATION: TA)(LOTNUMBEK DEVELOPMENTTYPE: NEW DWELLINGI}NITS 125 Yinccnt 66 r703262300608 SINGI.EFAMILY 0. STORM SYSTEM x COST PER S.F $0.336 COSTPERDFU $26.03 x $19.79 LOT SrTF (SF):BUILDING SIZE CIIARGE $108.07 TO CITY 0 DIRBCTRI]NOFT TO CITYI n,PERVIOUS S.F.I szz.w RTINOItr DRYWELL DESIGNED AND x ITEM T TOTAL. STOR]VI DRAINAGE SDC COST: x $10t.07 A B. ITEM 2 TOTAL - CITY SANITARY SE^WER SDC COST: COST: COST: x COST: COST: NUMBER OF I.}NITS 0 NUMBER OF UNITS 0 $4s8.17 COST PERTRIP $19.81 COSTPERTRIP s87.39 NEW TRIP FASTOR 1.00 NEW TRIP FACTOR 1.00 xx A B. xx ITEM 3 TOTAL - TRANSPORTATION SDC A B. MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMIMSTRATNTE FEE ITEM 4 TOTAL. MWMC SANITARY SEWER SDC St BToTAL (ADD ITEMS t,2,3, & 4) $0.00 CHARGE $28.3 r x xSIIBTOTAL s565.24 TOTAL SANITARY ADMIMSTRATION FEE: TOTAL TRA}.ISPORTATION Jeff Prociw zD\/2007 TOTAL SDC CEARGES IMPERYIOUS S.F. 0.00 DISCOUNT $0.00 NUMBEROFDFU"S l0 OFDFUS I DISCOUNTRATECOST PER 50o/o $961.52 $r0t.07 .91 $0.00 $0.00 $0.00 $594.55 1070 l09l rw2 1093 1094 1055 1054 1056 078 u) rqoo O & E]Fv) o E1d ADT TRIP RATE 9.57 ADT TRIP RATE 9.57 50.00 NTIMBEROFFEU'S 0 COST PER FEU $91.6r NUMBER OF FELIS 0 i56624 ADlv{- FEE RATE 5o/o PREPARED BY DATE lu-* x x x ESIDENCE COST PER FEU JOURNAL OR JOB NAME OR COMPANY: LOCATION: TAX LOTNUMBER: DEVELOPMENT TYPE: NEW DWELLING I.INITS DIRECT RLiNOFF TO CIry STORM SYSTEM CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT \ .(KSHEET 125 Vincent Crawford 66 1703262300608 SINGLE FAMILY RESIDENCE BUILDING SIZE (SF] O LOT SIZE (SF)0 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CIry ANDARDS lTFERvroffi.- x@ IMPERVIOUS S.F 0.00 COST PER S.F $0.336 COST PER S,F $0.336 COST PER DFU $26.03 $ 19.79 NUMBER OF TNITS 0 NUMBER OF UNITS 0 ADM. FEE RATE 5o/o DISCOLINTRATE 50% $108.07 DISCOUNT $0.00 x ITEM I TOTAL - STORM DRAINAGE SDC A. REIMBURSEMENT COST: NUMBER OF DFU'S a B. IMPROVEMENT COST: NUMBER OF DFU's -2 ADT TRIP RATE 9.57 B. IMPROVEMENT COST: ADT TRIP RATE 9.57 ITEM 2 TOTAL. CITY SANITARY SEWERSDC A. REIMBURSEMENT COST: x x x x x xx x COST PER TRIP $ 19.81 COST PER TRIP $87.39 $0.00 NEW TRIP FACTOR 1.00 ITEM 3 TOTAL - TRANSPORTATION SDC 4. SANITARY SEWER. MWMC A. REIMBURSEMENT COST: NUMBER OF FEU's 0 B. IMPROVEMENT COST: NUMBER OF FEU'S 0 SUBTOTAL $ r 6.44 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL. MWMC SANITARY SEWER SDC SUBToTAL (ADD ITEMS l,2,3, & 4) s0.00 sr6.44 CHARGE $0.82 x TOTAL SANITARY ADMINISTRATION FEE : TOTAL TRANSPORTATION ADMINISTRATION FEE Jeff Prociw U912008 TOTAL SDC CHARGES CHARGE $108.07 IUI@I $108.07 $0.00 $0.00 $0.00 $17.26 l 070 I 091 1092 I 093 t094 105 5 I 054 r 0s6 079 a E)oo O & E]Fa oHil TRIP F l.00 COST PER FEU $9 I .61 COST PER FEU $961 .52 PREPARED BY DATE brr-^- Cw>^-^{-* City of Springfietd Building Permit & Inspection Summary Te^ | t/25/2007 . 8:50:49AM Job #: coM2007-00125 225 Fifth Street 541-726-3753 Phone 541-726-3676Fax Project Status: Pending Job Address: 66 SHADY LP Springfield Scope of Work: Single Family Residence Description of Work: Addition to existing single family residence Name ELC OWNER MEC OWNER OWN CRAWFORD PLM OWNER Inspections t, cL Yl-u-r* Construction Tvpe V Wood Frame Valuation $46,968.00 Date Calculated Staff 2007101/25 DJB Owner & Contractor(s) Address VINCENT 66 SHADY LOOP Valuation of Proiect Cost Per Sq Ft Sq Fte $ 103.00 456.00 Fees Paid Date Paid Citv. State. Zip Phone SPRTNGFIELDOR 97477 541-744-3825 Occupancv Dwellings Description Plan Review Residential Total Amount Paid Department Amount Paid $229.52 s229.52 U-r-4--"' %+T-4-'""<- Plans Reviewed Due Date Comoleted Result Reviewer Comments Inspections Conducted Comments Date Receipt # 2200700000000000 I 09 Result Inspector I trj- va CLAlty=* 0t/25/2007 Received % S*n+"*t 5b' '2 Ow+,'t- lr^ril aY ;t*tr Y O-P f'4- h-2 I of I f- ,FZ L) A*AJ;f-'6'"'*4 'ti 25 I.'ifth Street pringfield, Oregon 97 477 4l-726-3759 Phone Citv ^f, Springfield Oflicial Receipt Dt pment Services Department Public Works Department RECEIPT#: 3200700000000000161 Date: 0312112007 l:11:49PM rb/Journal Number oM2007-00125 oM2007-00125 oM2007-00125 oM2007-00125 oM2007-00125 oM2007-00125 :OM2007-00125 roM2007-00125 :oM2007-00125 :oM2007-00125 :oM2007-00125 :oM2007-00125 :oM2007-00125 :oM2007-00125 :oM2007-00125 :oM2007-00125 )oM2007-00125 Description Fire SF Fee - Residential Storm Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Sanitaryi Storrn Admin Building Permit Fixhre Storm Sewer - lst 50 Feet Vent Fan Miscellaneous Mechanical Minimun/Adjusunent Mechanical Add, Alter, Extend Circ Add, Alter, Extend Circ Ea Add + 8% State Surcharge + l|Yo Administrative Fee Plan Review Minor - Planning + 5% Technology Fee Amount Due 22.80 108.07 260.27 t97.91 28.31 353.10 70.00 45.00 6.00 12.00 27.00 43.00 6.00 44.97 58.49 I12.00 33.71 Item Total $1,428.63 'ayments: 'ype of Payment Paid By Check Number Received By Batch Number Authorization Number How Received Amount Paid lreditcard VINCE CRAWIORD njm 015058 In Person $1,428.63 Payment Totat: -5T7i6F cReceiotl Page 1 of I 3/21/2007 El}ltltacrrGL,, Report lD : SPRA103A Voucher lD : Handling Code: 00129035 Crawford,Vince 66 Shady Loop Springfield, OR 97477 Description Account SDC Retunds of San/Admin 426604 448024 448025 Ciry of Springfield Voucher RE Accounting Date: Vendor Number: lnvoice Date : lnvoice # : Approver: Operator: Gross Amount : 2008 00 2008 00 2008 00 January/23l2008 oooo015471 March2112007 Com2007-00125 sTou9948 WLS594O 485.67 Amount 27.4s ,16 260.27 197.91 Fund Ogg Proi/Grant BY Terms 719 442 443 00000 00000 00000 Payment Message: Sanitary Sewer refund Comments: Was charged for fixfures that were exsisting in this remodel Shown on plans that they were exsting. .' IIiiii ~ City of Springfield _ Building Permit & Inspection Summary -;;:H_ I~'i '/1 1/25/2007 8:50:49AM Job #: COM2007-00125 225 Fifth Street 541-726-3753 Phone 541-726-3676 Fax Project Status: Pending Job Address: 66 SHADY Lp. Springfield Scope of Work: Single Family Residence Description of Work: Addition to existing single family residence Name ELC OWNER MEC OWNER OWN CRAWFORD PLM OWNER Owner & Contractor(s) Address City. State. Zip Phone VINCENT 66 SHADY LOOP SPRINGFIELD OR 97477 541-744,3825 Valuation ofProiect Occunancv Construction Tvne Cost Per So Ft So Fte; . Date Valuation Calculated Staff Dwellings V Wood Frame $ 103.00 456.00 $46,968.00 2007/01/25 $46,968.00 DJB Descrintion Amount Paid Fees Paid Date Paid Receint # Plan Review Residential Total Amount Paid $229.52 $229.52 01/25/2007 2200700000000000109 Plans Reviewed .Department Received Due Date Completed Result Reviewer Comments Inspections Conducted Inspections Comments Date Result Inspector . 0:J.r ~ 5~ry 'St)C-'P. Ol~ l,'^~,;.v.;I'~~ hf~h-~- ~~ j) tJr~I~~~ CL. ~~ 00 -tH-~ ~ C'~ M6. ..Q. "6 Q~ r. . . , ... 1-".-, _ l.. .. tLt~ +.~ 1f"..5~."...O ~ ~ 6~ lY~ D-- ~.. d fi~ 1 of I .' CITY OF SpAltFIELD SYSTEMS DEVELOPME~SHEET JOURNAL DR lOB NUMBER: C0M2o.o.7-llo.l25 NAME OR COMPANY: Vincent Crawford LOCATION: 66 Shady Lp TAX LOT NUMBER: 170.326230.0.608 DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE NEW DWELLING UNITS 0. BUll..DING SIZE (SF" 0 LOT SIZE (SF): J STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. . I COST PER S.F. I I CHARGE I l 322.00 I 50..336 = I $108.0.7 RUNOFF ROUTED TODRYWELL DESlGNED AND CONSTRUCfED TO CITY STANDARDS I IMPERVIOUS S.F. I . I COST PER S.F. I. I DISCOUNT RATE I I I 0..00 I I 50..336 I 50.% I = I ITEM 1 TOTAL. STORM DRAINAGE SDC 'SID8.D7 'I 1<1) I~ 10 IU I~ 0. , ~ -.<1) - " gj DISCOUNT SO.OO SID8.D7 11070 -' 2 SANITARY SEWER - Cra A. REIMBURSEMENT COST: I NUMBER OF DFU'. I . I COST PER DFU I 10. I 526.0.3 =, 5260..27 1091 B. IMPROVEMENT COST: I I NUMBER OFDFU'. I . I I . 10. . 519.79 I =, S197.91 11092 ITEM 2 TOTAL - CITY SANITARY SEWER SDC =, $458.17 I 3 TRANSPORTATION A. REIMBURSEMENT COST: I ADT TRIP RATE I. . I 9.57 I B. IMPROVEMENT COST: I ADT TRIP RATE I . I NUMBER OF UNITS I . I I 9.57 I . 0. I ITEM 3 TOTAL-TRANSPORTATION SDC =, COST PER TRIP 587.39 SD.oo I . INEW TRIP FACTOR! I 1.00 I = , SD.DD 11093 I . INEW TRIP FACTOR! , I 1.00 I SO.o.D 1094 I I NUMBER OF UNITS I . I I 0. I I COST PER TRIP S19.81 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: INUMBER OF FEU. I . ICOST PER FEU I 0. I I 591.61 B. IMPROVEMENT COST: INUMBER OF FEU. I . ICOST PER FEU I 0. I I 5961.52 MWMC CREDIT IF APPUCABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ITEM 4 TOTAL - MWMC SANITARY SEWER SDC = , SUBTOTAL (ADD ITEMS 1,2,3, & 4) . = , 5 ADMINlSTRA T1Vl' """L I SUBTOTAL . I ADM. FEE RATE 1= I 5566.24 I I 5% . TOTAL SANITARY ADMINlSTRATION FEE: TOTAL TRANSPORTATION ADMINlSTRATI~lN FEE: = SO.o.D 11054 I = SO.OO = , SO.OO = , SO.oo 1 lOSS 11054 .11056 I I SO.DD 5566.24 CHARGE 528.31 28.31 SO.o.o. 11078 PREPARED BY DA1E TOTAL SDC CHARGES = I SS94.SS I k\;':>W ~ C-k..--t~ _' Jeff Proeiw 2/28/20.0.7 JOURNAL OR JOB NUMBER: NAME OR COMPANY: LOCATION: TAX LOT NUMBER: DEVELOPMENT TYPE: NEW DWELLING UNITS I. STOR_M DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. x I COST PER S.F. CHARGE I 322.00 I $0.336 I = I $108.07 I RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S.F. I x I COST PER S.F. I x I DISCOUNT RATE I I 0.00 I $0.336 I 50% I = 1 ITEM I TOTAL - STORM DRAINAGE SDC 5108.07 I .' - 2. SANITARY SEWER - CITY. A. REIMBURSEMENT COST: I NUMBER OF DFU's I x I -2 I CITY OF SpaFIELD SYSTEMS DEVELOPMENT _KSHEET ,r:;-' t.Ll I@ I~ 1t.Ll f-o CIl a ~ COM2007-00 125 Vincent Crawford 66 Shad~ Lp 1703262300608 SINGLE F AMIL Y RESIDENCE o BUILDING SIZE (SF: o LOT SIZE (SF): o DISCOUNT $0.00 5108.07 11070 COST PER DFU 526.03 = , (552.05) 1091 I I = , ($39.58) 11092 = , '(591.63) I B. IMPROVEMENT COST: L NUMBER OF DFU's I x r -2 I $19.79 ITEM 2 TOTAL - CITY SANITARY SEWER SDC 3 TRANSPORTATION A. REIMBURSEMENT COST: r ADTTRlPRATE I x I NUMBER OF UNITS I x I I . 9.57 I 0 I I B. IMPROVEMENT COST: I ADTTRlPRATE I x I NUMBER OF UNITS I x I I 9.57 I 0 I I ITEM 3 TOTAL - TRANSPORTATION SDC = , ~. SANITARY SEWER, MWMC COST PER TRlP $19.81 x INEW TRIP FACTORI I. 1.00 = , I 11093 I 50.00 COST PER TRIP 587.39 50.00 x INEW TRIP FACTORI I 1.00 11094 50.00 A. REIMBURSEMENT COST: INUMBER OF FEU's I x o I B. IMPROVEMENT COST: INUMBER OF FEU's I x ICOST PER FEU . 0 I S961.52 MWMC CREDIT IF APPLICABLE (SEE REVERSE) MWMC ADMINISTRATIVE FEE ICOST PER FEU S91.61 = , SO.OO IOS4 = , 50.00 lOSS = , 50.00 1 IOS4 = , 50.00 IIOS6 I I ITEM 4 TOTAL - MWMC SANITARY SEWER SDC =, 50.00 SUBTOTAL (ADD ITEMS 1.2,3, & 4) = , S16.44 5. ADMINISTRATIVE FE!\; I SUBTOTAL x ADM. FEE RATE 1= I $16.44 5% . I TOTAL SANITARY ADMINISTRATION FEE: TOTAL TRANSPORTATION ADMINISTRATION FEE: Jeff Prociw PREPARED BY CHARGE $0.82 1/9/2008 0.82 SO.OO TOTAL SDC CHARGES =, $17.26 ,)(- k.!W s~ krv....<- ----,- ~ c..~ 1079 _11078 I I DATE 25 Fifth Street .pringfield, Oregon 97477 41-726-3759 Phone Cit.aSpringfield Official Receipt D~ment Services Department Public Works Department ,blJournal Number 0M2007-00125 0M2007-00125 0M2007-00125 0M2007-00125 0M2007-00125 0M2007,00125 0M2007-00125 0M2007-00125 :0M2007-00125 :0M2007-00125 :0M2007-00125 :0M2007-00125 0M2007-00125 :OM2007-00125 :0M2007-00125 :0M2007-00125 :0M2007-00125 'ayments: 'ype of Payment :reditCard cReccintl RECEIPT #: 3200700000000000161 Date: 03/21/2007 Description Fire SF Fee - Residential Stann Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Sanitary/Stonn Admin Building Pennit Fixture Stann Sewer - 1st 50 Feet Vent Fan Miscellaneous Mechanical Minimum! Adjustment Mecbanical Add, Alter, Extend Circ Add, Alter, Extend Circ Ea Add + 8% Slate Surcharge + 10% Administrative Fee Plan Review Minor - Planning + 5% Technology Fee Paid By VINCE CRAWFORD Item Total: l:heck Number Authorization Received By Batch Number Number How Received njm 015058 In Person Payment Total: Page I of 1 1:11:49PM Amount Due 22.80 108.07 260.27 197.91 28.31 353.10 70.00 45.00 6.00 12.00 27.00 43.00 6.00 44.97 58.49 112.00 33.71 $1,428.63 Amount Paid $1,428.63 $1,428.63 312112007 . .ITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2007-00125 ISSUED: 03/21/2007 APPLIED: 01/25/2007 EXPIRES: 09121/2007 VALUE: $ 46,968.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 66 SHADY LP ASSESSOR'S PARCEL NO.: 1703262300608 Springfield TYPE OF WORK: Single Family Residence TYPE OF USE: Addition Residential PROJECT DESCRIPTION: Addition to existing single family residence Owner: VINCENT CRAWFORD Address: 66 SHADY LOOP SPRINGFIELD OR 97477 Phone Number: 541-744,3825 I CONTRACTOR INFORMATION I Contractor Type Electrical Mechanical Plumbing Contractor OWNER OWNER OWNER License Expiration Date Phone Al ! Li' _ . -.,-""',, yuU to follow i lit:.!' <.ut 'o'! ,..) 0'/ i!1e Orecen um'y .+ ~._,_..... 'T~..._."" ....I,........ ....."'..........,,...-+ VB BUlLDlNG.INF0RMATlONI010 Ihrough OAR 952-00' J090. YOI' may ,)btain copies of.the rules i # o~ Stones:allio10 i11<l..:::mte:r. (~!ote:'rl1t~'3~bohone HeIght of Structure: \1 () 15.50, IJtS~,Ft~stiEtIOo~I:i)n :HtrlJogt "{)1: 1:? 1~,'.'~JI ...." I Vi~, .al Type of Heat: 'or.!Oed :AIr. Electnc. .,... ~q ;Et,nd loor: { "':\"\1':' ( I~ 1-., i I '-,lw' '.t'. "'~ ~-J. Water Type: '" '" . Sq'Ft Basement: Range Type: Sq Ft Garage/Carport Energy Path: Path I Sq Ft Other: Sprinkled Building: n/a Occupant Load: 456 # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: R-3 Fronlyard Setback: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: 7.30 I DEVELOPMENT INFORMATION I IOU Ilv&:. REQUIRED PARKING OverlaVDBt?ERMIT SHALL EXPIRE IF THE WQl!iJX # Streetl~ree$R!iiUD UNDER THIS PERMIT 1~lm'icapped: Paved@JI}iEflltq~0ED OR IS ABANDONED FO~ompact: % of 'tl'~fOtg6a5~y PERIOD. 25.00 9.00 I PUBLIC IMPROVEMENTS I Street Improvements: Storm Sewer Available: Special Instruction: Sidewalk Type: Downspouts/Drains: Notes: Some bldg envelope over existing impervious area. SDC.'s only include new impervious area fees.JLP 2/27/07 Paee 1 of 3 .'--11 y" OF ~rKlf"lt.J'IELD Building/Combination Permit PERMIT NO: COM2007-00125 ISSUED: 03/21/2007 APPLIED: 01/25/2007 EXPIRES: 09/21/2007 VALUE: $ 46,968.00 . Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-37691nspection Line I Valuation Descriotion I Description Tvpe of Constrnction $ Per Sq Ft or multiplier $103.00 Square Footage or Bid Amount 456.00 Owellines V Wood Frame Total Value of Project L.Fpp< PIilU Value Oate Calculated $46,968.00 $46,968.00 01/25/2007 Fee Description Amount Paid Date Paid Receipt Number Plan Review Residential $229.52 1/25/07 2200700000000000109 + 10% Administrative Fee $58.49 3/21/07 3200700000000000161 + 5% Technology Fee $33.71 3/21107 3200700000000000161 + 8% State Surcharge $44.97 3/21107 3200700000000000161 Add, Alter, Extend Circ $43.00 3/21107 3200700000000000161 Add, Alter, Extend Circ Ea Add $6.00 3/21107 3200700000000000161 Building Permit $353.10 3/21/07 3200700000000000161 Fire SF Fee - Residential $22.80 3/21/07 3200700000000000161 Fixture $70.00 3/21/07 3200700000000000161 Minimum/Adjustment Mechanical $27.00 3/21107 3200700000000000161 Miscellaneous Mechanical $12.00 3/21107 3200700000000000161 Plan Review Minor - Planning $112.00 3/21107 3200700000000000161 Sanitary Sewer - Improvement $197.91 3/21107 3200700000000000161 Sanitary Sewer - Reimbursement $260.27 3/21/07 3200700000000000161 SOC Sanitary/Storm Admin $28.31 3/21/07 3200700000000000161 Storm Drainage Impervious Area $108.67 3/21107 3200700000000000161 Storm Sewer - 1st 50 Feet $45.00 3/21/07 3200700000000000161 Vent Fan $6.00 3/21107 3200700000000000161 Total Amount Paid $1,658.15 I Plan Reviews I Initial Review 01/30/2007 02/02/2007 APP LLH Plan nine Review 02/02/2007 03/16/2007 APP TAJ Public Works Review 02/02/2007 02/02/2007 WI JLP Public Works Review 02/28/2007 02/27/2007 APP JLP Structural Review 02/02/2007 APP OLM 03/08/2007 Paee 2 of3 Rcvd 2/2/2007---Waiting in order PW rcvd for rvw.JLP Some bldg envelope over existing impervious area. SOC's only include new impervious area fees.JLP 2/27/07 Sent request for information to applicant 2/28/07dlm. Met w/ Mr. Lewis to explain requested info. 3/2/07dlm. Received requested info. 3/6/07dlm. " ,. -Lr.:.no. q . ~. . .ITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2007-00125 ISSUED: 03/21/2007 APPLIED: 01/25/2007 EXPIRES: 09/21/2007 VALUE: $ 46,968.00 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line To Request an inspection call the 24 hour recording at 726-3769. All inspections requested before 7:00 a,m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following work day, l_i~ww.~JI&~lP.~tions I Footing: After trenches are excavated. Foundation: After forms are erected but prior to concrete placement. Post and Beam: Prior to Ooor insulation or decking. Floor Insulation: Prior to decking. Framing Inspection: Prior to cover and after all rough in inspections have been approved. Wall Insulation: Prior to cover. Ceiling Insulation: Prior to cover. Final Building: After all required inspections have been requested and approved and the building is complete. UnderOoor Plumbing: Prior to insulation or decking. Underlloor Drain: Prior to cover or placement of concrete. Rough Plumbing: Prior to cover and including required testing. Storm Sewer Line: Prior to filling trench. Final Plumbiug: Wheu all plumbing work is complete. Rough Mechanical: Prior to Cover Final Mechanical: When all mechanical work is complete. Rough Electric: Prior to Cover Fiual Electric: When all electrical work is complete. By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and I further certify that any and all work performed 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 OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I furlher agree to ensure that all required inspections are requested at the proper time, that each address is readable from the street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during con tr. ction. . ~9 /~ "?-.:2j-O> Owner or Contractors siinat~ Date Paee 3 of 3 -\ } ", .." ", .,' . Construction Contractors Board 700 Summer St NE Suite 300 PO Box 14140 Salem OR 97309-5052 Phone: 503-378-4621 Web Address: www.ccb.state.or.us Permit #:Col'V\oz.oo~o ( 7.. S- LfJ Address: 6 b ? fA k L, Issued bYh..Jamd- ~ I ) U Date: :$/;)1 J(J7 Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the folloWing statement before a building permit can be issued. This statement is required for residential building, electrical, mechanical and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010(7), need not submit this statement. This statement will be filed with the permit. Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 3B: ~l. ~2. I own, reside in, or will reside in the completed structure. I understand that I must become licensed as a construction contractor if the structure is sold or offered for sale before or on completion. D 3A. My general contractor is (Name) (CCB #) I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR ~3B. I will be my own general contractor. If! hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If! change my mind and hire a general contractor, I will contract with a contractor who is licensed with the CCB and will immediately notify the office issuing this building permit of the name of the contractor. I hereby certify that the above information is correct and that I have read and do understand the Information Notice to Property Owners about Construction Responsibilities on the reverse side of this form. ~ ~ / -:7S--&;> , (SignatUte orit applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant.) Property_owner.doc 06-01-04 .- . Adnllllg tal~ li ij])1lllJl" ((])Wllll CGtellllteJl"talll C({j)llll~Jl"tal~~({j)Jl"? INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES NOTE: This Information Notice to Properly Owners about Construction Responsibilities was developed by the Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature. If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and concerns. IEm/Plnoyer Re!)/PloIIn!)fillJifinfitfie!) You will, in most instances, be ruled to be an "employer" and the contractors you contract with will be "employees" if you use contractors not licensed with the Construction Contractors Board to do labor in constructing or to assist in the construction or improvement of a residential structure. As the employer, you must comply with the following: Oregon's Withholding 'fax Law: As an employer, you must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Department of Revenue at 503-378-4988. Unemployment insurance Tax: As an employer, you are required to pay a tax for Wlemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488. The Oregon Business Identification Number (BIN) is a combined number for both Oregon Withholding and Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or www.dor.state.or.us/fonnsoav.htmll for the appropriate forms. Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you could be subject to penalties and be liable for all claim costs if one of your employees is injured on the job. For more infonnation, call the Workers' Compensation Division at the Department of Consumer and Business Services at 503-947-7815. U.S. Iuternal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be liable for the tax payment even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 1-800-829-4933 or visit their web site at www.irs.l!ov. OtltneJl' ResJPiollllsJiIbJillitJies amll Alt'eas oil' COIlllCelt'llD.S Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements that may be brought to your attention through inspections. Liability and Property Damage Insurance: Contact yout insurance agent to see if you have adequate insurance coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe pWlctures, fire or work that must be redone. Time: Make sure you have sufficient time to supervise your employees. Expertise: Make sure you have the skills to act as your own general contractor, to coordinate the work of rough-in and finish trades, and to notify building officials as the appropriate times so they can perform the required inspections. If you have additional questions call the Construction Contractors Board (503-378-4621) or write the agency at PO Box 14140, Salem, OR 97309-5052. Property _ owner.doc 06-01-04