HomeMy WebLinkAboutPermit Building 1993-09-25IELO
RESID ENTIAL
PERMIT APPLICATION
lnspections: 726'3769
Of f ice: 726-3759
JOB NUMBER
225 Flfth Street
Springfield, Oregon 97 477
LOCATION OF PROPOSED WORK:
ASSESSORS MAP:TAX LOT
LOT
-
BLOCK:SUBDIVISION:
-
To request an inspection, you must call 726-3769. Thls ls a24hour recording. All lnspectlons requested before 7:00 a.m. wlll be
made the same worklng day, lnspections requested after 7:00 a.m. will be made the following work day.
REQUIRED INSPECTIONS
Temporary Electric Flnal Plumbing - When all
plumblng work ls complete.
Site lnspection - To be made
after excavation, but prior to
setting forms.
Underslab Plumbing / Electrical /
Mechanical - Prior to cover.
Footing - After trenches are
excavated
Masonry -beams, grou
Foundation
erected but
placement.
Underground Plumbing - Prlor
to filling trench.
Underlloor Plumbing/Mechanical
- Prior to insulation or decking.
Post and Beam - Prlor to floor
insulation or decking.
Floor lnsulation - Prior to
decklng.
Sanitary Sewer - Prior to fllllng
trench.
Storm Sewer - Prior to filllng
trench.
Waler Llne - Prlor to fllllng
trench.
Rough Mechanical - Prior to
cover.
Rough Electrical - Prior to
cover.
Electrical
Wall/Ceiling lnsulation - Prlor to
cover.
Drywall - Prior to taplng.
Wood Stove - After lnstallation.
lnsert - After flreplace aPProval
and installation of unit.
Curbcut & Approach - After
forms are erected but prior to
placement of concrete.
Sidewalk & Driveway - After
excavation ls complete, forms
and sub-base material ln place.
[-l Fence - When completed
Street Trees - When all requlred
trees are planted.
Flnal Electrlcal - When all
electrical is complete.
cal - \\then all
al work ls complete.
Flnal Building - When all
required lnspectlons have been
approved and building is
completed.
Other
MOBILE HOME INSPE TIONS
Blocking and Set.Up - When all
blocklng ls complete.
Plumblng Conneclions - When
home has been connected to
water and sewer.
Electrical Connection - When
blocking, set-up, and plumbing
inspections have been approved
and the horne is connected to
the servlce panel.
Final - After all requlred
inspections are.approved and
porches, sklrtlng, decks, and
ventlng have been installed.
PHONE:
ZIP:STATE:7
CITY:
7 (F/.<5f
ADDRESS:
OWNER:
NEW
-
REMODEL ADDITION DEMOLISH OTHER
DESCRIBE WORK:
ELECTRICAL: ol
PHONEEXPIBESADDRESS
DID
It
tt
)&zGENERAL:
PLUMBING
MECHANICAL:
CONST.
CONTRACTOR #CONTRACTOR'S NAME
FIANG E:
- OFFICE USE -
ZONING CODE:
FLOOD PLAIN:
SECONDARY HEAT:
SQUARE FOOTAGE:
OUAD AREA:
r OF BLDGS:
LAND USE:
WATER HEATER:
OCCY GROUP:
* OF STOBIES:
CONSTB. TYPE:
HEAT SOURCE:
# OF UNITS:
-
Rough Plumbing - Prior to
cover.
atnr-u
E
E
tf
E
fl
E
tl
E
tl
lnsp.
- Prior to cover.
fl tl
E
E
# OF BDRMS:-
E
Lot laces
Lot sq, ltg.
Lot coverage
TopographY
Total helght
Lot Type ?
-
lnterior
-
Corner
-
Panhandle
-
Cul-de'sac
ks \IS-1 HE PROPOSEO WORK IN THE
HISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTER?
-
lf yes, this application must be slgned
and approved bY the H lstorlcal
Coordinator prior to permlt issuance.
APPROVED:
t
ACCP.L.HSE GAR
N
s
W
E
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on the express condition that the said
constructlon shall, in all respects, conlornr to the Ordinance
Receipt Number:-
cD_^Wte,-'
thendelcnudnciofStedhepnadobyvp
onti useand oflatlUnheconstrucCode,nt sDeveregopme
metlatUSdanyrevokedorbependeay
inances,rdsaidooflonsprovisany
Recel
bulldlngs, and m'
upon vlolatlon of
Plan Check Fee:
Date Pald:
BUILDING PERMIT
|TEM sQ. FT. X $/SQ. FT. = VALUE
(A)
Total Value
Bulldlng Permlt Fee
State Surcharge
Total Fee
Maln
Garage
Carport
Systems Development Charge is due on all undeveloped
properties withln the City limits which are being lmproved'
ADDTTIONAL COMMENTS
SYSTEMS DEVELOPMENT CHARGE (SDC)
FEE
(B)
(c)
Plumblng Permlt
State Surcharge
Total Charge
Resldentlal Bath(s)
Sanltary Sewer
Water
Storm Sewer
Mobile Home
PLUMBING P
ITEM
Flxtures
MECHANICAL PER
,\
t5
T
(D)
Dryer Vent
Unlt
Mechanical Permlt
lssuance
State Surcharge
Total Permlt
Furnace
Exhaust Hood
Vent Fan
Wood Stove/lnsert/
i
By slgnature, I state and agree, that I have carefully examlned
the completed applicatlon and do hereby certlfy that all
ln{ormation hereon is true and correct, and I f urther certlfy
that any and all work performed shall be done in accordance
with the Ordinances of the City of Springfield, and the Laws
ol the State of Oregon pertainlng to the work descrlbed
herein, and that NO OCCUPANCY wlll be made of any
structure wlthout permisslon of the Bulldlng Safety Dlvlslon'
I further certlfy that only contractors and employees.who
are ln compllance wlth ORS 701.055 wlll be used on lhls
project.
I further agree to ensure that all requlred lnspectlons are
requested at the proper time, that each address ls readable
lrom the street, that the permlt card ls located at the front
of the property, and the approved set of plans wlll remaln
on the site at all times during constructlon'
ignature
Date l-z
MISCELLANEOUS PERMITS
Total Mlscellaneous Permlts (E)
b
A--
VALIDATION:
RECEIPT NUMBEB
DATE PAID
AMOUNT RECEIVED
RECEIVED BYTOTAL AMOUNT DUE (excludlng electrical)
(A, B, C, D, and E Comblned)
Aq:a--TV
/v2 c/friEP /y'-^ r' ^' , ,,-
Moblle Home
Slate lssuance
State Surcharge
Sldewalk
-
lt
Curbcut
-
fl
Demolltlon
State Surcharge-ila.;frr ' 'ffi 7a
1 LOCATION OF INSTALIJ\TION
I,EGAL ON
JOB DES(NIPTION
Permits are non-transferable and expire
lf vork is not started vithin 180 days
of issuance or if vork is suspended for
180 days.
2. CO}T1"ACf,OR INSTALI.ATION ONLY
Electrical Contractor
Address
Ci ty Phone
Supervisor License Ntimber
.Expiration Date
Constr Contr. Number
Exp iration Date
Signature of Supervising Electrician
0wners Name
Address
ab
3 g1s.oo ZE
ELECTRI CAL PERH IT APPLICATION
IL City Job Nuurber,
1l$ l. coHPLETB tBE ScTEDULE BBLov
A Nev Residential-Single or
HuIti-Family per dwelling unit.
Service Included:
Items Cost
_< $ ss.oo #
specific land
225 FIFTE SITEEf,
SPRINGFIBLD, ORBGON 97477
INSPBCTION REQUEST: 726-
OPFfCE: "726-3759
Authorized Signatwe.
B
s 40.00
Services or Feeders
Installation, Alterations or
Relocation:
200 amps or ]ess
20L amps to 400 amps _401 amps to 600 amps _
601 amps to 1000 amps_
0ver 1000 amps/volts
Reconnect 0nly
C. Temporary Services or Feeders
Installation, Alteration or Relocation
1000 sq.ft. or less
Each additional 500
sq. ft or portion
t hereo f
Each Manuf 'd llome or
Modular DueIling
Service or Feeder
E
5. SUBTOTAL OF ABOVE
5Z State Surcharge
TOTAL
200 amps or less S 40.00
201 amps to 400 amps _ $ 55.00
Over 401 to 600 amps _ $ 80.00
Over 600 amps or 1000 volts see [Brl
Sum
M
$ s0.00
$ 60.00
$100.00
s130.00
s300.00
$ 40.00
D. Branch Circuits
Nev, Alteration or Extension Per Pane1
s 3s.00One Ci rcui t
Each Addi tional
Circuit or vith Service
or Feeder Permi t
Miscellaneous (Service/feeder
-Each installation
Pump or irrigation $
Sign/0utIine Lighting- S
Limi ted Energy/Res $
Limited Energy/Comm $
a66ve
s 2.00
not included)
40. 00
40. o0
20. oo
ciw Ui1 , vnone 74 7- /AO?
OSNER INSTALI,ATION
The installatlon is being made on
property I own vhich is not intended
for sale, Iease or rent.
Ovners Signature:
DATE: -
RECEIVED BY
414
t
fu/'d/'-/
SPRINGFIELO
RESIDENTIAL
PERMIT APPLICATION
lnspections: 726-3769
Office: 72A8759
LOCATION OF PBOPOSED WO
ASSESSORS MAP:
JOB NUMBER
225 Filttt Strcet
Sprlngtlclcl, Oregorr 97477
TAX LOT:,
LOI:
-
BLOCK
OWNER:
CITY:
ADO
STATE:
PHONE
ztP
NEW
-
REMODEL ADDITIO
DESCRIBE WORK:
GENERAL:
ADDFIESS EXPIRES .1 PHONECONTRACTOR'S NAME
ELECTBICAL:
MECHANICAL:
PLUMBING:
CONST.
CONTRACTOR #
_ OFFICE USE -
, OF BDRMS:
r OF UNITS:
HEAT SOURCE
LAND USE:QUAD AREA:
r OF BLDGST
FLOOD PLAIN:
ZONING CODE
SECONDARY HEAT:
SOUARF- FOOTAGE;
OCCY GROUP:
r OF STORIES:
CONSTR. TYPE:
--
WATER HEATEFI:FIN NGE:
To request an lnspecilon, you must call 7
made the sanre worklng clay, lnspectlons
26'3769' Thls ls a 24 hour rccordlng. All lnspections requested belore 7:00 a.rn. wlll bercquested after 7:00 a.m. wlll be macje the followlng work day.
REOUIRED INSPECTIONS
l-_l Temporary Etectrtc f{aougtt
-
cover.
ffiechanlcal - Prlor toq00
{Eleclrlcal - Prlor to
Final Plumbing - When.allplumblng worl< ls complete.
Slte lnsp€ctlon - To be madcalter excavation, but prlor tosettlng forrns.
Rough Flnal Eleclrlcal - When allelectrlcal worl( is complete.
cover
I--l Underslab Plumblng/Etectricat/
-
Mechanlcal - prlor to cover.Eleclrlcat Servlco - Must bcapproved to obtalrr permanent
electrlcal power.
f{rrnat Mechantcat - Whcn ail
-
mcchanical work ls cornplcto.
Foollng - Alter trenches are
excavated.Flnal Buildlng - When allrequired lnspectlons have beenapproved and buildlng is
completed.[-l Masonry - Steet tocaUon, boncJ
-
beams, grouilng.
Flreplace - Prlor to faclng
materlals and framlng lnsp.
l-l Framlng -. prlor to cover.
Foundatlon - After forms areerecled but prlor to concrete
placemont.
Other
Wall/Celling lnsulatlon - prlor to
cover.
[-l Underground plumblno - priorU lo fllllig trenctr [--l Drywall - Prlor to taptng.
Tl Underlloor plumblng/Mcchanlcal
Prlor to lnsulatlo-n or Oeckf ng. f-l Wood Stovo - Af tcr tnstailatlon
MOBILE HOME INSPE TIONS
Posl and Boam - prlor to floorlnsulatlon or decklng,lnserl - After flreplace approvaland lnstallatlon ot unlt.
I-*l Blocking and Set.Up _ When ail
-
blocklng ls complete.
Floor lnsulallon - prlor to
deckl ng.Curbcul & A1:prroach - Afterforms are erocted btrt prior toplacemcnt of concret<:.
Plumbing Connections - Whenhome has been connected towater and sewer.Sanllary Sewer - prlor to fllllng
tronch,
[-l Storm Sewor - l)rior to filting'J trench.
Sidewalk & Drlveway - Afterexcavalion ls completc, formsand sub.base material ln place.
Fence - Wtren completed.
Electrical Connection - Whenblocklng, set.up, and plumblng
inspcctions have been. approvedand tlre home is connected tothe servlce panel.Waler Llne - Prlor ro lilling
trench.
Rough Plumbing - prior tc)
cover.[-_] Str€et Troos - Whcn all rcqutred
-
trees are planted.
Final - Af ter all requiredInspections are approved andporches, sklrtlng, decks, andventlng have been lnstalled.
SUBDIVISION:
tl
I
Lot faces
Lot sq. ftg.
Lot coverage
Topography
Total helgh(
Lot Typ-
-
lnterior
-
Corner
-
Panhandle l
-
Cul-de-sac
backs IS THE PROPOSED WOFIK iN THE .
HISTORICAL DISTRICT, OR ON
TI]E HISTORICAL REGISTEFI?
-
lf yes, thls appllcatlon must be slgned
arrd approved by the Hlstorlcal
Coordinator prlor to permit lssuance.
APPROVED:
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on the express condition that the sald
construction shall, in all respects, conform to the Ordlnance
adopted by the City of Springfleld, includlng the
Development Code, regulating the constructlon and use of
bulldings, and may be suspended or revoked at any tlme
upon violation of any provisions ol sald ordlnances.
Datc Pald
Receipt Numbe
Received By:
Plans RcviewccJ By Date
Systems Developmcnt Charge is due on all undeveloped
properties within thc City linrits whiclr are being lmproved.
ADDITIONAL COMMENTS
VALIOATION:
RECEIPT NUMBER
DATE PAID
AMOUNT REC
TOTAL AMOUNT DUE (excluding clectrlr:
(A, B, C, D, and E Comblncd)
PL.HSE GAR ACC
N
S
E
VALUE
(A)
x $/so. FT.
Total Value
Building Permit Fee
State Surcharge
Total Fcc
BUILDING PERMIT
ITEM SO. FT.
Main
Garage
Carport
SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
ITEM
Flxtures
Resldcntlal Bath(s)
Sanitary Sewer
Water
Storm Sewer
Moblle Home
FEE
(c)
No
FT.
FT.
PLUMBING PERMIT
Plumblng Permlt
State Surcharoe
Total Charge
Wood Stove/ lnsert/Flreplace Unlt
trL
I
*3Qo
(D)
tMecnical
NoVent Fan
lssuance
MECHANICAL PERMIT
Furnacc
Exhaust Hood
State Surcharge
Total Permit
By slgnature, I state and agree, that I have carolully examlned
the completed application and do hereby certlfy that all
lnformation hereon is true and correct, and I lurther certlf y
that any and all work performed shall be done ln aocordance
wlth the Ordinances of the Clty of Sprlngf leld, and the Laws
o{ the State of Oregon pertalnlng to thc work descrlbed
hereln, and that NO OCCUPANCY wlll be mado of any
structure wlthout perrnission of the Bulldlrlg Safety Dlvislon.
I further certlfy that only contractors and employees who
are ln compllance wlth ORS 701.055 wlll be used on thls
proiect.
I f urther agree to ensure that all requlred inspections are
roquested at tho proper tlmo, that oach address ls roadable
from tlro street, that the permlt card ls located at the lront
of the property, and the approved set ol plans wlll remaln
on the slte at all times durlng constructlon.
sls
o-Date
MISCELLANEOUS PERMITS
Moblle Home
State lssuance
State Surcharge
Sldewalk
-
ft
Curbcut
-
ft
Demolitlon
State Surcharge
Total Mlscellaneous Perrnits (E)
FTECEIVED
D
Plan Check Fee:
-
FT.
TELI)Z/o
JOB NUMBER
EEB'ff'1.ISi'"o''o*
lnsDections: 72G'37GS
c-ltlice,726-3i59
?rt,
225 Filth Street
i-pli ngri,,ro, oregon 97477
1310
--N IL
r oC,ATr\ o
nssrssohs
F PROPOSED WOT1K
MAP
TAX LOT:
ISUBDIVISION:
A
L
3PHONE:
i1Ll-77zlPSTATE:
I1,
h t.
?
I
ALADDRESS:
CITY:
NEW
-\
,_ RL:MODEL ADDITION DEMOLISH OTHER
DESCRIBE WORK
CONTRACTOR'S NAME ADDNESS
CONST.
CONTRACTOR #EXPIRES PHONE
HG EN ERAL:
ttl -
l\,4ECHAN ICAL: -, ------
I')I,LJ MRING
ELECTRICAL:
OLJAD ARFA:
It OF IlLDGli: .
OCCY CROUP:
s oF sTol-ltF-s:
\N./ATER I-IEATER:
lffiBrtt D-
_ OFFICE USE _
DUSE:- llll-- ---
yl
It
LA t'l
N
IlANGE:E
Rough Mechanical - Prior to
cover.
Rough Electrical - Prior to
FLOOD PLAIN:
ZONING CODE;
# OF BDRMS
SECONDARY HEA-N
SQUARE FOOTAGE:
_J # oF UNITS, -- I
Ra_a-
4 M_CC)NSTR. TYPE: -
I_IEAT SOURCE
-- -,.---aJ.-_2144
l-o request an inspection, you musl call 726-3769. This is a24 hour recording. All inspections requested before 7:00 a.m. will be
macie the same working cl:ry, inspections requested atler 7:OO a.m. will be macte the following work day.
REQUIRED INSPECTIONS
[-_l Ternporary Elcclrictt
Site lnspection - To be rnarJe
af ter excavation, but prior tcr
setting forms.
Undersl ectrical/
Meclranic to cover,
Masonry - Ster:l location, bond
bearns, groutin0.
Foundalion * After {orrns arr-'
erecteci but prior t0 concrete
placement.
Underground Plunrbing - Prior
to filling lrer'rch.
U nderf Mechanical
- Prior to u a on or decking
Post and Beam - Prior to lloor
insulation or decl(ing.
Floor lnsulation - Prior to
decl(ing.
Sanitary Sewer - Prior to f illing
t rcn c tl.
Storm Sewer - Prior to filling
trench.
Water Line - Prior to filling
tr(]nch.
Rough Plumbing - Prior'to
cover.
OOVCI,
Electrical Service - Must be
approved to obtain permanent
electrical power.
Fireplace - Prior to faclng
rnaterials and f raming lnsp.
Wood Stove - After installation
lrrserl - After fireplace approval
and installation of unit.
Curbcut & Approach - After
forms are erected but prior to
placement of concrete.
Sidewalk & Driveway - Af ter
excavation is complete, forms
i:ntl srrb-basc.. ntatcrial in place.
Ferrce - When completed
Street Trees - When all required
trees are planted.
IYT Final Electrical - Wlren all4\clectrical work is complete.
,K
Final Plumbing - When all
plumbing worl( is complete.
Final Mechanical - When all
mechanical worl< is complete.
,x
}<
X
E
EI I::j;::"- Arter trenches are
K
A
E
E
B
r,
K
K
X
Vl f inal Buildino - When allJ^\.r..qr, r"d i nsp"ections have been
apprroved and building is
completed.
ffiotn-'ng - Prit>r to cover'
f\/ w;rttlcciling tnsulation - Prior to
,lA{ r:r>ver.
D(otr*r'l - Prior to tarrins.
Olher
MOBILE HOME INSPE TIONS
Blocking and Set-Up - When all
blocking is complete.
Plumbing Connections - When
home has been connected to
water and sewer.
Electrical Conneclion - When
blocking, set-up, ancl plumbing
inspections have been approved
ancl the home is connected to
the service panel.
Final - After all reqr-rired
lnspections are approved and
porches, skirting, decks, and
venting have been installed.
umbi
lu nr
r
a r\/ l/'l
I trl
,l
-- EYt/
tl
E
ri
tl
tl
fl
Lot faces
Lot sq. ftg.
coverage
Topography
Total height
Lot Type --
-
lrrterior
-
Corner
-- Panhandle
-- Cul-de-sac
S(ltbacl(s
HSE GAR ACC//Fzoefi
129o
2G
PL.
N 2{)t
J
/o I
E
IS T}1 [ F'ROPOSED WORI( IN THE
H tsTo RtcAL DtsTRrcr, o-g_*oN
THE HISTORICAL REGISTEFI? :
lf yes, this application must be signed
and approved by tlte Historical
Coordinator prior to permit issuance.
APPFIOVED
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This pernrit is granted on tlre express condition that the said
construction shall, in all respects, conform to the Ordinance
adopted by tlre City of Springfield, including the
Developrnent Code, regulatirrg the construction and use of
buil<Jings, and may be suspended or revoked at any tinre
violation of any provisions of said ordinances.
lJ;rtc*
2*
3/zu pon /6[)lan Cltt:c;k ['cc
/o-s -7L
Date Paid
Receipt Number:.
VALUE
oo/fuFO
(A)
_f6?a
Z6
Total Value
Building Permit Fee
State Surcharge
Total Fec
X $/SQ. FT.
BUILDING PERMIT
ITEM SO. FT.
Main
Garage
Carport
a4enrh
Systems Developnrent Clrarge is clue on all undeveloped
properties within tlre City limits wlrich are being improved'SYSTEMS DEVELOPMENT#tsfile
ADDITIONAL COMMENTS)lITEM
Fixtu res
Residential Bath(s)
Sanitary Sewer
Water
,
Storm Sewer
Mobile Home
PLUMBING PERMIT
FEE
N0
(\-)
4
FT.
FT.
FT.
- /%-?:
Plumbing Permit
State Surcharge
Total Chargc
463ffii
Wood Stove/ lnsert/ Fireplace Unit
MECHANICAL PERMIT
Mcchanical Permit
?v4
Ooo
_ _( t__---
(D)
N0
.b.@1frf
/a.e
Dryer Vent
ar-&
3/,oo@
lssuance
State Surcharge
Total Permit
Fu rnace
Exhaust Hood
Vent Fan
-a 2O4t
By signature, I state and agree, that I have caref ully exanrined
the completecl application and do hereby certify that all
information hereon is true and correct, and I f urthcr certif y
that any and arll worl< performecl shall be done in accordance
with the Orclinances of tlre City of Springf icld, and thc Laws
of thc State o( Oregon pertaining to the work described
herein, and lh.at NO OCCUPANCY will 'be made of any
structure without permission of the Building Safety Division'
I further certify that only contractors and employees who
are in compliance witlr ORS 701.055 will be used on this
proiect.
I f urther agree to ensure tlrat all required inspcctions are
requested at the proper time, that each address is readable
lrom the street, that tl're permit card is located at the front
of tl-re property, anci the approvecl set of plans will renrain
on the site a I times dr.rring construction
(
ignatu rc
Date
MISCELLANEOUS PERMITS
Mobile Home
State lssuance
State Surcharge
Sidewalk --__ {t
Curbcut
-----
ft
Demolition
St;rtc Surcharg;c
Total Miscellaneous Permits (E)
D -.27/a7:
7?
RECEIVE AY
DATE PAID
AMOUNT FI
VAI.-IDATION:
RECEIPT NUM
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, D, and E Combined)
44i***?
21
t?\v
Recei/@.,2s24-t/
aA
2r.OO
i0B N0.1u zbo
CITY0FSPRINGFIELD-SI!E.I'ISDEVEL0PMENTCHARGEWORKSHEET
(C0I'IMERCIAL & RESIDENTIAL)
NAME OR COMPANY:Mt uUAF-P
AL-t..ltJf ob - ooloo
LOCATION:o
DEVELOPMENT TYPE VVZ - TJ{-VI *?
T SIZ . Ft.
BUILDING SIZE:
1.STO DRAi AGE
IMPERVIOUS SQ. FT.2boo x $0.192 PER SQ- FT-
SANITARY SEWER-CITY
NO. OF PFU'S IO X $39.78 PER PFU
(See Reverse)
?
3. T SPORTAT ION
NO OF UNITS X TRIP RATE X COST PER TRIP
I XI .oo5 X $401 .05
X
Y
ADMINISTRATiVE FEES
BASE CHARGE (SUBT0TAL ABoVE) X '05
5. SANITARY SEWER.Mt^lMC
NO. OF PFU'S
x $401 .05
x $40i.0s
SUBT0TAL (ADD ITEMS 1,2, & 3)bse
lo
$13.62 PER PFU + $IO MhIMC ADMIN. FEE $zr59
4
(Use PFU Total From
MbIMC CREDIT IF APPL
ttem 2 Above)
ICABLE (SEE REVERSE)
TOTAL-MWMC SDC
TOTAL SDCKip Burdick
.*4t Go
, ottlo-
SDC Coordinator
lo 2-
s
TOTAL-CiTY SDC
$lqq,v qo
FIXTURE UNIT CALCUIATI6N rngLE: r.rumoer of New Fixtures X ti.rn Equivalent = Fixture Units (NOTE
For remodets, calculate only the Nfl additional Iixtures)
NUMBER oF UNIT FIKIURE
FIXTURE TYPE NEW FIXTURES EQUIVALENT UNITS
Bathtub...-.-.
Drinking Fountain-.---
Floor Drain.
I nterceptors For Grease/Oil/Solids/Etc""""""""'
lnterceptors For Sand/Auto Wash/Etc"""""""""
Lau nd ry Tub/Clotheswasher"""
Clotheswasher - 3 Or More"""
Mobile Home Park Trap (1 Per Trailer)"""""""""
Receptor For Ref rigeratorAVater Station/Etc" "" "
Receptor For Commercial Sink/Dishwasher/Etc"
Shower, Single Stall-...------..-
Shower, Gang...-...---.
Sink, Bar, Commercial...--.."-""""'
Urinal, StallflVall--L
Wash Basin/Lavatory, Single'
Water Closet, Public lnstallation'Z ---6-
Water Closet, Private..-------
Ir4iscellaneous
TOTAL FIXTURE UNITS lb
CREDIT CALCULATTON TABLE: Based on assessed value. lf improvements occurred after annexation date in table'
calculate credits
I
--z-
--z
2
1
2
J
6
2
6
6
1
J
2
t /Head
2
Z
1
6
4
Credit for Parcel or Land Only lf Applicable
lmprovement (if after annexation date)
x$
(Rate X Assessed Val ue)
X$
(Rate X Assessed
CREDIT
Value)
TOTAL =$N,* .
RUNOFF COEFFICIENTS FOR STORM DRAINAGE
Residential--
Commercial 0.9
lndustrial-.
.--------..-----""' 0'4
Year
Annexed
Rate per $1,000
Assessed ValueYear
Annexed
Rate per $1,000
Assessed Value
1 985
1986
1 987
1988
1 989
'1990
1991
$2.1 6
1.90
1.60
0.25
0.87
0.50
0.16
1979 or before
1980
1981
1982
1983
1984
$2.83
2.76
2.7'l
2.60
2.46
2.33
IMPERVIOUSAREA:TOTALLoTSIZEXRUNOFFCOEFFICIENT
?-
Permit No:
Address:
lssued Date:
OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4) , requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement will befiled with the permit.
Fill in the plicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
1 I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
My general contractor is ,
2
3.A
OR
Contractor registration numbe
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
3.8 I will be my own general contractor.
lf I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. lf I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor.
! hereby certily that the above inlormation is correct and that t have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
-L 6 -?3
ignature o t cant
CONSTRUCTION CONTRACTORS BOARD
0244J 8t91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
Date
INFORMXTION NOTICE TO PROPERTY OfiTNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTE: This lnformation Ndice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
'passed by the 1989 Oregon Leg,islature. :
'(':". .- : :' .'
lf you ar'e actinQ ab yourown contraetor tb construct a new home or make a substantfrf.+dEi$rcm"ni to "nexisting structure, you canprevgnt many problems bylbeing aware of the following responsibilities and areas'ir . :ol concern
:1.':' ' o; i
EMPLOYER RESPONSIBILITIES:
lf you hire pe{sols, not registered with the Construction Contractors Board tp do labor in constructing or assisting
in the consrruction or iripfot'e#entbf a'rBsidentiAl structure, you wili, in miist instancgs, be'ftrted to be an
"employer" andihq'pepple you hire will be "pmployees'0, As,t{r.e.FmRioyer,.you,p(t$t comply'with the following:
-|{'
Oregon's Withholding Tax.Law:, As a1,gmployer, you tnust.withhold incglJre- taxes f19rm emp,loyee wages at
uwili6eliable,forthetaxpaymentsev.en.ifyoudonltactuallywithholdthe
tax from your employees. For more information, call the Oregon Department of Flevenue at 378-3390.
Unemployment lnsurance Tax: As an employer, you are required to pay a tax for unemployment insurance
mployees.Formoreintormation,oal],theOr9gonEmploymentDivisircnDHR
at 378-3224.
Workers'Com sation lnsurance: As an employer, you are sarbiect to the Oregon VlA)rkers' Compensation
Law, and must n workers' compensation insurance for your employees. lf you fail to obtain workers'
compensation insurance, you may be subject to penalties and will be'lihble for allc{aim costs if'onb of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at g&7434.
You will be liable for the tax payment even if you d
r must withhold federal income tax from employees'wages.
idn't actually withhold tn" U*. fdr more infoimation, call
U.S. lnternal Revenue Service: As an employer, you
the lnternal Revenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code Cqqp!!g!qe: As the permit holder for this proiect, you are responsible for resolving any failure to meet
coOe requirements that may be brought to your attention through inspections.
Liabil and .insurancb: Contact your insurance agent to see if you have adequate insurance
coverage for accidents and omrssrons suc h as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re-done
Time.tO Supervise Employees: Make sure you have sufficient time to supervise your employees.
Expertise:
of rough-in
Make sure you have the expertise to act as your own general contractor, to coordinate the work
and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
lf you have additional questions, write to:Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
o244J 10124189