HomeMy WebLinkAboutPermit Building 1991-12-05SP]lINGFIELD
e.r€
BLOCK:
s
;.4 4 ct
LOCATION OF PROPOSED WORK:
JOB NUMBER
TAX LOT:
SUBDIVISION
ASSESSORS MAP:
LOT
RESIDENTIAL
PERMIT APPLICATION
lnspections: 726-3769
Office: 726-3759
225 Fifth Street
Springfield, Oregon 97 477
PHON E:
CA q 5ll6ZIPSTATE:
bi
l+'. * LctS
foseSonCITY:
ADDRESS:
OWNER:
5 40 Bonil-a-
€.xi#,iu^r, Hon- too be Mo*.| -M
NEW ,/ REMoDEL ADDrroN DEMoLTSH orHER
TDESCRIBE WORK J
ADDRESS EXPI RES PHONE
lt
tu,
€A
C\N huo
h
4,e
CONTRACTOR'S NAME
7S5W L
+65-gkq
MECHANICAL:
ELECTRICAL:
CONST.
CONTRACTOR #
Tlor gekrfuol qLt
GENERAL:
PLUMBING
OQ 17 44o Lict 5?
-8*
WATER HEATER:RANGE:
* OF BDRMS:
OFFICE USE _
\\\ \
ZONING CODE:
FLOOD PLAIN
* OF UNITS:
SECONDARY HEAT:
SQUARE FOOTAGE:
LAND USE:
OCCY GROUP:
* OF STORIES:
/a
QUAD AREA:
# OF BLDGS
CONSTR. TYPE:
HEAT SOURCE:
To request an inspection, you must call 726-3769. This is a24hour recording. 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.
REQUIRED INSPECTIONS
[--l Temporary Electric
t-___l
Rough Mechanical - Prior to
cover.
Final Plumbing - When all
plumbing work is complete.
Site lnspection - To be made
after excavation, but prior to
setting forms.
Rough Electrical - Prior to Final Electrical - When all
electrical work is complete.cover.
Underslab Plumbing/ Electrical /
Mechanical - Prior to cover.
Electrical Service - Must be
approved to obtain permanent
electrical power.
Final Mechanical - When all
mechanical work is complete.
Footing - After trenches are
excavated.Fireplace - Prior to facing
materials and framing lnsp.
w Final Building - When all
required inspections have been
approved and building is
completed.Masonry - Steel location, bond
beams, grouting.
Foundation - After forms are
erected but prior to concrete
placement.Wall/Ceiling lnsulation - Prior to
cover.
Underground Plumbing - Prior
to filling trench.f_l Drywall - Prior to taping
MOBILE HOME INSPE TIONS
Underlloor Plumbing/Mechanical
- Prior to insulation or decking.Wood Slove - After installation
Post and Beam - Prior to floor
insulation or decki ng.lnsert - After fireplace approval
and installation of unit.
Blocking and Set-Up - When all
blocking is complete.
Floor lnsulation - Prior to
decki ng,Curbcut & Approach - After
forms are erected but prior to
placement of concrete.
Plumbing Conneclions - When
home has been connected to
water and sewer.
Sanitary Sewer - Prior to filling
trench.Electrical Connection - When
blocking, set-up, and plumbing
inspections have been approved
and the home is connected to
the service panel.
Slorm Sewer - Prior to filling
trench.
Sidewalk & Driveway - After
excavation is complete, forms
and sub-base material in place.
Water Line - Prior to filling
trench.
Fence - When completed.
Street Trees - When all required
trees are planted.
Final - After all required
inspections are approved and
porches, skirting, decks, and
venting have been installed.
Rough Plumbing - Prior to
cover.
w
4?a /
l--l Framing - Prior to cover.
tl
tl
f_-l other
E
Lot faces
Lot sq. ftg.
Lot coverage
Topography
Total height
Lot Type ,_
Y hterior
-
Corner
-
Panhandle
-
Cul-de-sac
Setbacks
nze
Eo/e-
J THE PROPOSED WORK IN THE
HISTORICAL DISTRICT, OFI ON
THE HISTORICAL REGISTER?
-
lf yes, this application must be signed
and approved by the Historical
Coordinator prior to permit issuance.
APPROVED:
PL.HSE GAR ACC
N //'
S _9
?/'
E 76'.
X $/SQ. FT,VALUE
,o,fu
2,5V
/<*fuqzq
(A)f?,ov
Total Value
Building Permit Fee
State Surcharge
Total Fee
BUILDING PERMIT
ITEM SQ. FT.
Main
Garage
Carport
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMTT
This permit is granted on the express condition that the said
construction shall, in all respects, conform to the Ordinance
adopted by the City of Springfield, including the
Development Code, regulating the construction and use of
buildings, and may be suspended or revoked at any time
Date
//^822
:trPlan Check Fee
Date Paid
Receipt Nu
Received By:
upon violation of d ordinances.
SYSTEMS DEVELOPMENT Cr%ree tfreoq,/qqe/27ed4.7q ,F4Y/<€> . (B)
HARGE (SDC)
N,4,
ITEM
Fixtures
Residential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
FEE
4O
/. €a
N0
(c)?/.3
-,A 5
FT. ?S
Fr. < fu' 25
Of -oa
PLUMBING PERMIT
Plumbing Permit
State Surcharge
Total Charge
ADDITIONAL COMMENTS
Wood Stove/ lnsert/ Fireplace Unit
Dryer Vent
(D)
N0Vent Fan
Mechanical Permit
lssuance
State Surcharge
Total Permit
MECHANICAL PERM!T
Furnace
Exhaust Hood 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 Building Safety Division.
I further certify that only contractors and employees who
are in compliance with ORS 701.055 will be used on this
project.
I f urther 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 f ront
of the property, and the approved set of plans will remain
on the site at all times during construction.
- t) -Date
Sig natu re
MISCELLANEOUS PERMITS
Mobile Home
State Surcharge414e actkpaa'ir- /3
H
Curbcut /4 tt
L?.2
/2.7o
Total Miscellaneous Permits (E)z€.+
Demolition
State Surcharge
State lssuance
TOTAL AMOUNT DUE (excluding electrica\ /ZZ:2e
(A, B, C, D, and E Combined)
=
DATE PAID f?-5-? a
VALIDATION
RECEIPT NUMBER &vz 5 2-
EIVEDAMOUNT FIEC
RECEIVED BY
-;F
Systems Development Charge is due on all undeveloped
properties within the City limits which are being improved.
1t
.PFtINGFIELE)
BLOCK:
LOdAI ION OF PROPOSED WOFIK
SUBDIVISION
TAX LOT:AS:;i:S:]OI]S MAP:
LOT:
JOB NUMBER
NTSIDENTIAL
PERMIT APPLICATION
lnspections:726-3769
Of (ice: 720-3759
225 Fif th Street
Sprinofield, Oregon 97 477
4c.-PHONE
olL ZIPS'I-ATE:
t)
1
oCIIY:
ADDRESS:
OWtIER
0 L,l
"L ADDrroN DEMoLtsH orHER
DESCRIBE WORK:
NEW
-
REMODEL
ELECTRICAL:
EXPI RES PHON EADDRESS
Oll).a)'=a- -
CON'TRACTOR'S NAME
CONST.
CONTRACTOR ,/
CENET'IAL:
f,I-UMRING:
MECHANICAL:
RANGE:
_ OFFICE USE _
LAND USE:
WATER HEATER:
* OF UNITS:
r OF BDBMS:
ZONING CODE:
FLOOD PLAIN
SECONDARY HEAT
SOUARE FOOTAGE:
OUAD AREA:
r OF BLDGS:
OCCY GFIOUPT
,/ OF STORIES
CONSTR. TYPE:
HEAT SOURCE:
To requcst an inspection, you must call 726-3769. This is a24nour recording. All inspections requested be
nlacle the same working day, inspections requested after 7:00 a.m. will be made the following work day.
REOUIRED INSPECTIONS
re 7:OO a.m. will be
I -' I Temporary Elcclric
ll I '-l nough Meclranical - Prior toLl cover.Xm.,?#lilltp Wlren all
completc.
t_]Site lrrspection - To be made
etf tcr cxcavation, lrut Prior to
setting forms.
Rouglr Eleclrical - Prior to Final Electrical
t-.lt-'ctrical worh i i Whcn all
complete.cover.
Underslab Plumbing/ Electrical /
Mechanical - Prior to cover.
Electrical Service - Must be
approved to obtain Permanent
electrical power.
Final Mechatric
nreclranical wot
:dl
ri<- When all
is complete.
Footing - After trenches are
excavated.Fireplace - Prior to facing
materials and framing lnsP.
Final Building - When all
required inspections have been
approved and bJilding is
completed.Masonry - Steel location, bond
beams, grouting.Framing - Prior to cover.
Other
Foundation - After forms are
erected but prior to concrete
placement.Wall/Ceiling lnsulation - Prior to
cover,
Underground Plumbing - Prior
to filling trench.f-l Drywall - Prior to taoing
N SPE TIONSMOBILE HOME t
Underlloor Plumbing/ Mechanical
- Prior to insulation or decking.Wood Stove - After installation
Blocking and Sgt.Up - Wlren all
blocking is complete.
Plumbing Connections - Wlten
home has been connected to
water and sewel.
Posl and Beam - Prior to floor
insulation or deckin0.lnserl - After firePlace approval
and installation of unit.
Floor lnsulalion - Prior to
decki ng.Curbcut & ApProach - After
forms are erectecl but Prior to
placement of concrete.Sanitary Sewer - Prior to f illing
trench.Electrical Conndction - When
blocking, set-upr and plumbing
inspections have been approvcd
and the horne i9 connected to
the service pan$1.
Storm Sewer - Prior to filling
trench.
Sidewalk & DrivewaY - After
excavation is comPlete, forms
and sub-base tnaterial in Place.
Water Line - Prior to filling
trench.
Street Trees - When all requlred
trees are planted.
Final - After all required
inspections are approved and
porches, skirtin$, decks, and
vcntinO have bepn installe(1.Rough Plumbing - Prior to
t7CI1 s,\' i<o
2@ 17. Ir)qbo
*n/sP,
Lf
t:]
r
fl
tl
fl
tl
E
n
tl
E
[l fence - When comoleted.
Lot fa<;cs
Lot sq. {tg.
Lol coverage
TopographY
Total height
Lotvpe
--
lnterior
-.-,
Corner
---- Panhandle
-
Cul-de-sac
Setbacl<s
ACC
E
P.L I-ISE GAFI
N
IS I IIE PFTOPOSED WORK IN THE
IJISTORICAL DISTIIICT, OR ON
TI-IE HISTORICAL REGISTER?,.- -,-_
lf ycs, this applicalion must bc signcd
and :rpproved bY tlrc Flistorical
Coordinator prior to permit issuancc.
APPROVED:
BUILDING PERMIT
ITEM
Main
Garage
Carport
SQ. FT. X T;/SQ. FT,VALUE
Tolal Value
Builrtin.q Pcrrrtit Fee
Stalc Surcharge
Total Fee (A)
BUILDING VALUE, PLAN CHECK
AND BUTLDING PERMIT
This perrnit is grantecj on t[re express conditiorr tllat ttlc said
construction shall, in all respects, conform 1o the Ordinance
adopted by the City of Springfield, including the
Development Coclc, regr.rlating ttre construction an(l tlse of
builclings, and may be suspencled or rcvol<ed at any tinre
upon violation of atly provisions of said ordinarrccs
Plan Check Fee: .-.
Date Paid
Rcccipt Ntttttbcr:
[lcceivecl By
Plans [it-'vicwr-'cl UY D;rtc
SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
Systems Developtncnt Chargc is due on all undevelol cd
properties wil.hin thc City linrits which arc being itnprovr:rl.
PLUMBING PERMIT
ITEM
Fixt u res
Residential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
FEE
_3lfltury
No
{,rO
FT.
FT.
Plunrbinq Pertnit
St;rte !)urcltargle
Total Clrarge
f4'
(c)3/,t"
ADDITIONAL COMMENTS
MEC]IANICAL PERMIT
Fu rnace
Exhaust Hood
Vent Fan No
Wood Stove/ lnsert/ Fi replace Unit
Dryer Vent
Mechanical Permit
lssuance
State Surcharge
Total Permit (D)
By signature, I statc arrd agree, that I have caref ully exatttined
the cornpletecJ application and do hereby ccrtify that all
information hereon is true and correct, and I f urthcr certify
that any and all work petformed shall be dotrc in accordancc'
with the Ordinances of the City of Springfield, and the Laws
of the State of Oreg;on pertaining to the worl< rlcscribed
herein, and that NO OCCUPANCY will be nri,r<le of atty
structure wilhout pcrrnission of the Building Safcty Division.
I f urther certify that only contractors and employees wl-to
are in compliance with ORS 701.055 will be used on this
proiect.
I further agree to ensure that all required inspections are
requested at the proper tinre, that each address is readable
from the street, that the permit card is located at the f ront
of the property, and the approved set of plans vrill remain
on the site at all ti cs du g construction
gnatLlrc
oare
-*2:='7-*-.-9
2
MISCELLANEOUS PERMITS
Mobilc Hotne
St.ite lssuar"lcc
Statr: [iurclt;rrqe
Sidewalk - tl
Cut[;cLtt {t
Doilioliticin
Iil;rlo I ittrt;lt;tt11t:
Tot;rl Miscellaneous Permits (E)
TOTAT AMOUNT DUE (exoluclinrJ eloctrical)
(A, U, C, D, rrnrl E Gotntrirrecl)
to
VAI-IDATION:
n[:ct--.1 I,l' Nt Ih4 I ] t-l l
DATE PAID..-_
AMOUNT RECEIVED
FIECEIVI:N I1\/
3Br>f-
2 -24- .i'2
7/.{a
FT.
C'T OF SPR'NGFIEL OREGO'V
225 FIFTE STREEf,
SPRINGFIELD, OREGON 97477
INSPECTI0N REQUEST: 7
0FFICE: 726-3759
1 OF INST
Electrical Contractor
Address
ci Phone 48581116
Supervisor e Ntimber 3555
Expiration Date \D IqL
fs r-
IJGAL DESCRIPTION
Permits are non-transferable expi reif vork is not started vithin 180 days
of issuance or if vork is suspended for
180 days.
2. COIITRACf,OR INST
Constr Contr. Number 5q1 47
Expiration Date
Signature of Supervising Electrician
0 4/* i
Ovners Name
Address
,-'City f 54226 Phone
-
OVNER INSTALI.^ATION
The installation is being made on
property I ovn which is not intended
for sa1e, lease or rent.
Ovners Signature:
DATE: 2^z
RECEIPT
CAL
City Job Number
PEE SCEEDULE
t ial-SingIe
uI t i-Fami Iy per dwell
Service fncluded:
I tems
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereo f
Each Manuf'd Home or
Hodular DweIling
Service or Feeder
Services or Feeders
Installation, Alterations o
Relocation:
i
200 amps or less I201 amps to 400 amps _
401 amps to 600 amps _
601 amps to 1000 amps_
0ver 1000 amps/volts
Reconnect Oniy
Hiscellaneous ( Service/feed
-Each installation
Pump or irrigation
Si gn/0ut1ine Ligh t ing_
Limited Energy/Res
Limi ted Energy/Comm
-ST,BTOTAL OP ABOVE
5Z State Surcharge
TOTAL
,TION
BELOTI
or
ing uni t.
00$Bs
0040$
Cost Sum
s 1s.00
$100.00
$130. 0o
s300.00
$ 40.00
OM,Y B
r
$ s0.00
$ 60.00 @
c
D.
Temporary Services or Feeders
Installation, Alteration or Relocation
200 amps or less S 40.00
201 amps to 400 amps _ $ 55.00
Over 600 amps or 1000 volts see t'B[ above
Branch Circuits
Nev, Alteration or Extension Per Panel
s 3s.00One Circui t
Each Additional
Circuit or vith Service
or Feeder Permi t $00
r not included)
I
E t
00
00
00
00
40.
40.
20.
36.
$
s
s
S
5
RECETVED BY:
.4'Lll'1t[:*rOnt^ D
^.
t,
63 q2-
(D
-r*-'
L_l
I
WHITE COPY TO ISSUING AGENCY PERMTT FILE
PINK COPY TO APPLICANT
1
2
195584-91
Permit No
Address:
lssued bate:
OR OFFICE USE dNLY
STATEMENT:
INFORMATION NOTICE TO PROPERW OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential construction permit
applicants who are not registered with the Construction Contractors B{ard to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plqmbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement yttill be
filed with the permit.
Fill in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
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.
A My general contractor is
Contractor registration number-
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
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,corltractor, 1 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.
I hereby oertily that the above information is correct and that I have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
gnature o rm pp cant
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
3
,dl
'rD'zlz
,k8",
Date
C'TY OF ONEGO'U
225 FIFTE STREEf,
SPRINGFTELD, oREGoN 97477
INSPECTI0N REQUESTz 726-376
0FFICE: 726-3759
1. LOCATION OPs
ELECTRICAL PERHIT AP
City Job Number,
c0H SCEEDULE BELOS
Residential-Single or
Hulti-FamiIy per dvelling un
Service Included:
I tems
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereof
Each Manuf'd Home or
Hodular Dvelling
Service or Feeder
Services or Feeders
fnstallation, Alterations o
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 Feed
Installation, Alteration or Relocation
LEGAL DESCRIPTION-o3
ON
Permits are non-transferable and expireif vork is not started vithin 180 days
of issuance or if vork is suspended for
180 days.
2. CONTRACf,OR INSTALI.ATION ONLY
Electrical Contractor
Address
city- Phone
Supervisor License Number
Expiration Date
Constr Contr. Number
Expiration Date
Signature of Supervising Electrician
0vners Name
Address s'? t w ll4 A u(
Ci ty Phone 3+- I,
OVNER INSTALI,ATION
The installation is being made on
property I ovn vhich is not intended
for sale, lease or rent.
0vners S ture:
DATE: 2- -- qz-
RECEIPT D
2ir
200 amps or less
201 amps to 400 amps
-Over 401 to 600 amps _
Over 600 amps or 1000 volt
STMTOTAL OP ABOVE
5Z State Surcharge
TOTAL
Branch Circuits
Nev, Alteration or Extension Per Panel
One Circui t
Each Addi tional
I
Circuit or vith Service
or Feeder Permit i 5 $ z. oo 1-6
Miscellaneous (Service/feeder not included)
-Each installation
Pump or irrigation S 40.00
Sign/0utline Lighting_ S 40.00
Limited Energy/Res
Limi ted Energy/Comm
s 20.00
s 36.00
i
s
$
$
t
40.
Sumt
00
00
00
Cos
85.
15.
00
00
00
00
00
00
B
130.
50
60
100
300
40
$
$
$
$
$
$
s
$
$
$
40 00
oo
0o
'grr sf,[][s see It
s 3s.oo 35
55
80
B I D
E
RECEIVED BY:[-V\l-
5
,io cl
oa
JOB
INSPECTIONS 726.3769
CI'fY OI: SPITINGIT IELD
225 North 5th Street
t]UI LDING MOVINC PER}IITIBUILDING DIVISION
BUSINESS 726.3753
OLD ADDRESS
gaI Descr rp t on
t703 35 33
/hr,trt^ h,ru-6 0( S"*r4. ?-
d by Building Div.
44NEIlI ADDRIJSS F'urnishe
Legal Descript on
/703 5s s b o440t
ng er
S
Phone
S{/\Lil
PhoneCS S
/{wp,t
res s
//\hr//*
Ert,rry hrttAnttA a7c31 Y-9.( S.IITFS>
rmg Lics Exp.
D escript ron ntended Uses/J
Descri ptron o Il,oute
/n*r,ou^, /or- //**r^Lawt a
CITY DIISIGNATED JOll Nul\lllERo/5
flonata f^l t. (u'ra) , C*rrr,-. , P,ourr.- (*, W
S, Q,! r?K
Description o[' l]uilding
Square Footage I'lo ving Lcngtn /e'
Number 0f Sections Being I'loved
l4ovin g lrlidthlS lleight on Doll l? '/o"
Iype 0f Constructi on fle4,a+ V ALUATIoN -€
NO'IIFICATION OF l.lOVE: 'l'he lJ uL lcling Division
rvill route copies of this application to all
appropriate divisions, departments and Agen-
cies. tl0llEVER, thc applicant must contact
property owners if trees are involved in the
proposed move. IN ADDITION, the applicant
must secure the approval of alI appropriate
municipal, county and state authorities
should the move originate or terminatc out-
side the City of Springficld.
SElVElt CAI,: llu 1 I I ngs moved from tv l. IlItlr c
City limits shall havc tlte scwer capped at
the property line and inspected one working
day prior to tlte move. If thc inspection
indicates that the sewer ltas not been prop-
crly cappcd, thc moviltg llernrit rvil l be
revoked.
and that no changes
also certify that I
ll,AVE ELASPED. I fur
force and effect as
noted hereon. Basis
PLANS, FEES, AND CIIARGES: Prior to rcceiv-
ing a permit to move a buildirlg to property
within the City, the applicant or his/her
authorized representative must :
1. Submit 2 copies of site or plot plan
for new site.
2. Submit 2 copics of foundation plan for
the relocated building.
3. 0btain a permit covering the ncw fotrnda-
tion, as well as alt plumbing/mechanical
and electrical work relating to the re-
located bui ldittg.
4. Pay Systems Developmetrt Chargc if appli-
cabl e.
SIrP'IIC 1'ANK IREI,IENTS: Prior to mov ing,
owner shalt have all sludge from the scptic
tank, seepage pit or ccsspool rcmoved by a
person holding a sewage dispoat service li-
cense, ancl shatl fill same with clcan bar-
run gravel or other material approved by the
rector or ltis authorizcd rescntati vc.
I CERTIFY TIIAT tlrc abovc information is truc and correct, that all rerl trircd contacts hnve
bcen macle and autltorizittiolts obtaitrcd, that thc movc will bcgi orclock I)ilt
on }4C. k _1/!_t-rn<l rvill be conrptcted by
nat
@/o' clock pn on
1n the route will be made w thout con tacting the Bui 1 ng Divisi
have been informecl that NO PERI,IIT WILL BE ISSUED BEF0RE 5 IV0RKING
ther certify that my registration with the Builderts Board is in
rcquired by ORS 701.055 and 701.070, and that if exempt the basis
for Builderrs Board ExemPtion:
n. I
DAYS
fu11
is
NAIllE &,rrr4 /rcdetuqrra SIGNATURE D^rE/td>(l
FOR OITFI CE USE ONLY
Zone
Stori es
Flood Plain
Living Urtits
of Construction Occupancy GrouP
Sq uarc Footage VALUE
/lt
Application fcc $13.00 -- Datc
Permit fee $60.00 -- Date Paid 2
Nunrbcr of lllocks ovcr 6 0 .60+x.A
Paicl / /^ 27 -9t Rcceipt Number
Receipt Number
4Amount
Seurer Cap $fg1Oo *-{g6.'St"te Surcharge -- Date Paid ?-42 r
PoIice DePartment
Fire Department
Northrvest Gas
OTIILR sPcc i fr'
lVillamalene Park and Rccreat Rai nbow lVater / SL,ll
Pacific NIV Bel l
-Lane Transit District
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-Group ltr Cablc
LaneCotrntyAGT
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BUILDING I'I()VING I I,IIT
I. App'licant to furnish (except as indicated)
A. 0ld address for building
B. Legal DescriPtionC. New address for building
(guitding Div. wjll furnish)
D. Legal DescriPtionE. Name, etc. of building owner
F. Name, etc. of moving firm
G. A description of intended useH. A description of ProPosed route
I . A descri pti on of the bu'i'ldi ngII. Applicant to contact property owners if trees
invo'lved, and secure authorizations front
other jurisdictions as necessary.
A site or plot plan, and foundation plan must
be submitted for the new site (2 sets)
Plans must also be subrnitted for any other
work relating to the relocated building.
Fees & Charges:A. Application fee due and payabl e at time
of appl icationB. Moving perm'it fees due and payable upon
permi t i ssuanceC. FEES & CHARGES TO BE CALCULATED BY
BUILDING DIVISION STAFF
FOR OFFICE USE ONLYA. ,Plan check data collectedB. Copies of application to appropriate
divisions, departments and agencies
)ERMIT VALIDATION
III.
IV.
V.
VI.
PERMIT CLERK tu
BUILDING DIVISION REPORT:
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TRAFFIC DIVISION REPORT:brz+ Ot/€4s a A.///-t
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B Date
ENGINEERING DIVISION REPORT:
Date z
ADDITIONAL PROJECT INFORMATION :
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