HomeMy WebLinkAboutPermit Demolition 1980-01-28L CITY OF SPRINGFIELD
COMBI I{ATI ON APPL I CATION/PERMIT 7?5-
Job Address l+4 t
l-ega1 Description
EIIERGY SOURCES
Hea t
l.later Heater
Ranqe
n
Sq. Ftg. Access._
Sq. Ftg. 0ther--
_l,ler,rr_Add-Al ter_Pe p.
_Fence_Demo Change/Use
-other-
o
Owner
Value of l.lork
Address Phone n t Info: Describe Work g.,S ng e
cons$rct\Jn le-nae,,t
Addre s s Phone
DESIGN TEAI.I name address I (licsi no.pxn res phone no.
Pri ma ry
Structura I
El ectri cal
Mec han i ca I
CONTRACTORS name address )lics- no-')(pxnires'(ohone no-)
x-'/*
PI umbi no
El ectri cal
Itlechanical
PLUIlB I NG ELECTRI CAL MECHAN I CAL
NO FEE CHARGE NN FFF C HARGF NO FFF CHARGF
Each single fixture Residence of
SO. FT
furnace/burner to
BTU' S
Relocated building
(new fix. additional)
New ci rcui ts al ts.
or extensions
Floor furnace
and vent
S . F. P,es i dence
( I bath)SERV I C ES
Recessed wal l
Snacp hpatpr and vpnt
Duplex (1 bath) each
Additional bath Temporary Construction Apol iance vent
se Da rate
l.iater servi ce Change in existing
rps i dpncp
Stationary evap.
cool er
Sewer multifamily, cornm. or
Industriai
Vent fan with
sinole duct
Storm Sewer 0f amps.Vent systern apart from
heatino or A.C.nn o.SJ)oW 'lD oo cor.il.l./IND. FEEDERS
Mechan i cal exhaust
hood and duct
I Insta l I /al ter/rel ocate
di st-ri b- feeders l'Jood stove/heater
0f amps.
ISSUANCF OF PFRIIIT
TOTAL CHARGES IOOU TOTAL CHARGES TOTAL CHARGES
WHERE STATE LAl,l REQUIRES that the Electrical work be done by an Electrical Contractor, the electrical portion of this permit
shall not be vali'l until the label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXAMINED the completed application for oermit, and do hereb.y certify that all information hereon is true
and correct, and I further certif.v 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 0regon pertaining to the work described herein, and that NC OCCUPAI{CY will be made
of any structure without the permission of the Building Division. I further certify that m.y registration vtith 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 ernployees who are in comcliance with 0l?S 701.055 wi"lI be used on this Dro,ject.
l,lAtlE(pl ease pri nt)t n s=-HEZA'T-S ICiIATURE T
FON OFFICE USE Oi.ILY
Zone-Iype/Cons t Uni ts S o. Ftg. l'lain x Val ue
Fire Zone Bedrooms Occy Load S q. Ftg. Acce Value
Flood Plain Sto ri es Group Sq. Ftg x Value
DunD ToTAL VALUATI0N_
0ther
BUTTDI]VTPERI'ItT
Charges and
Surcharges
l oo PIan Ck. Comm,/Ind
65%/B1do Per Fee
Svstems Deve
Charqe (1.5%
opment
Plan Ck. Res
30%/81dq Per Fee
PLUI4BING PERMIT
Charges and
Surcha rges
I Fence
Dgmo
ELECTRICT.L PERI,IIT
Charges and
Surcha rges
Sidewal k
A/C Paving
Curb Cut
Total Comb. Permit
14ECHANICAL PERMIT
Charges and
Surc ha rges TOTAL tr qc
.No
q
IN))y
\r
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnishA. Job AddressB. Legal Descriptionl. example- Tax Lot 100, Lane County Map Reference
t7 03 432. example- Lot 1. Block 3, Znd Addition to
S[n-n-gTieia EstatesC. Name, etc. of owner and construction lenderD. Energy Sources1. example- heat/e1ect1!rql ceiling/2. examEle- waterheateiTETecTilcilE. Squar- Tootage or val uat jon-tc.
or forced air qas
r sol ar
l. example- 1250 sq. foot house, 500 sq. foot garage2. exampie: iFnew project, check-new - if addition,
check add, etc.F. Building permit information:1. example - construct single family house with an
attached garage2. example - remodel existing garage into family room3. example - convert single family residence into- restaurant (change of use)G. Value of work as defined in Section 303 (a) of the
H
Structura I
DESIGN TEAI4
Specialty Code
AND CONTRACTORS
To avoid design or construction delays, Building
Division Staff must be able to contact appropriate
persons regarding design information or job sitecorrections, etc.
Abbreviated Plumbing, Mechanical, & Electrical SchedulesA. Except where blank spaces occur in the descriptionportion of the Mechanical and Electrical Schedules,
the applicant need fill-in only the No. Boxes adjacentto the appropriate item(s) to be installedB. Ful l Plumbing, Mechanical, and Electrical Schedules
are available at the Building Division1. To conserve space on the permit form the schedules
have been abbreviated?. If the item(s) to be installed are not covered onthe abbreviated schedules you should consult thefulI schedulesC. BUILDING DIVISION STAFF hIILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULESD. As noted on the CAP, the label must be delivered to theelectrical contractor for signature by his electricalsupervisor. The general contractor is not authorized
II
to sign the electrical labelIIL Applicant to sign and date
Whenever possible, the initial applicat'ion will be used asa worksheet only. Where possible, Building Division Stafflrill prepare a type written copy and return it to theapplicant at the time the actual permit is.issued for hissignature.IV. Fees and Charges
PIan check fees are due and payable at the t.ime of theapplication, and no p)ans w.ill be processed until thesefees are paid. All other fees and charges are due andpayable vrhen the permit is issued.
V. FOR OFFICE USE ONLY
PERMIT VALIDATION
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Permit Clerk
PROJECT CONDITIONS TO BE SATiSFIED BEFORE OCCUPAI{CY:
Permit applicant exempt from registrat'ion r^lith the Builder's Board because:
Add'itional Project Information :
PLANS REVIEWED BY:
name SI gna tu re da te