HomeMy WebLinkAboutPermit Building 1981-08-28CITY OT SPRINGTIETD
COMBINAIICN APPIICATION / PERT^II
INFORMAIION TINE
7263753TNSPECIION IINE
726-37 69
\tr it,Primo
Strucluro I
heron, ond thot only rubconrractors ond employeor who qrc in omplionca with ORS 70I.055 will be on this proiccf.
8o:ir for Builder'r Boord exemption:
NAJr{E (pleore print)
-
SIGNATURE
rOR OTFICE USE ONTY
Zone _1 .Typc/ Conrr. - Units I 5q. Ftg. /rloin
firc Zona-Scdroomr ccy Lood Sq. Ftg. Accerr
Flood Ploin Storiet-Occy Group Mlt Sq.Other
-
NO
Electricol
nqmc)
Plum
Electricol
/'lcchonicol
2iUMBING ETECTRICAT MECHANICAI
F?'CHARGE NO.FEE CHARGE NO
iurnoce/burner io
IOIAT CHARGES
WHER€ sTATE tAW REOUIRES thor thc Ehdrirol work ba done by the Elc.trical Conlroctor, tha rlcclricol portion of thir permit rholl not br volid unril c
lobel hor bcca ignod by on Elactricol Conlroctor ond ot o(h!d to thc ahctricol poncl,
IHAVE CAIEFULIY EXAI*INED the compleied opplicotion for permil, ond do hareby catlifY tho? oll informoiion hereon is true ond corrccl, ond I furthcr
<ertify thot ony ond oll work pcrformed sholl be done in occordqnce with the Ordinonces of the City of Springficld cnd the Lowr of lh! Slote of Oregon
pertoining to rhe work dercribeci herin, ond fhot NO OCCUPANCY will bc mode of ony ltructurc withoul lha prrmir:ion of fhe Building Division. I furrher
ertify thot my rcgirtotion witir the Builder's Boord ir in full forcc ond effect or required by ORS 701.055, lhot if exempt the bosir for cxemption ir notcd
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t'1- 02- 3Legoi Dercriotion
tt9. MoinSq
5q
Sq
Volue of Work:
Buildinq Permit lnfo:
hedReridenccFomrl
-Other
ttg. Accesr.
Delcribe Work (i.e., Euild Sing le
Wo ler deote(
-_New
-Add -Alter -ReP'- -Fence.-Demo-Chongcl'Urc
Ft9. Othcr
EN€R,GY SOUR,CES:
Heot
Phone
Owner
Add rc r:
S.
\s
Conrtruction I-endr
Addrerr Phone
(lig. no.)(oddre:r)(no meiDESIGN TEAM no.)(
FEE
Reridence oi
fr.Eoci rinqla fixtvrc I
I
I
I
Applionce vent
sepqrote
New circuits. olleroliotrs
or extensions
I
I
I
Relocorcd builciing
(new iir. odcjitionol)
Slolionorl, evop
coolerSERVICES
i
I
5.F. Rer,dencc
(l both)
/o,0D
Vent forr with
:inqie CuclTemporory ConttruciionDuolex {l bolh} eo<h
I
I
Vent ryrtem oport from
heoting or A.C.Ampr.Aciditionol borh
Mechonicol exhourt
hood ond duct/D.D,'ttr JuL lrrr,t-IIWoter rervicc
Wood srove/ heoter rUt t-)o^DoScwertl
Heol PumpFEEDE RS
Air hondler lo
r0,000 cF,$iA I-C. DI Ampr.I
Se*cr
Air hondler ovrr
10,000 cfMI
ISSUANCE Ct PERitAIT
TOTAI, CHARGES 70,NTOTAT CHARGES 7s,po
/ tnd Syrtemr Development
Demo folol Comb. Permil
ch I2C_---Jlz B Per Fee
Per Fec
Plon Ck-
Plon Ck. Re:
s'uttfttccER7[I? ,C,
PTUA,{8ING PERA{II
Chorger ond
Surchorger
!}:.r1:lt 5d
ETECTRICAL PERMII
Chorger ond
Surchorger -_-_ x.la
c
Sidewoik
MECHANICAI. PERMIT
Chorqer ond
Surchorger
Curb Cut
TOTAL
TOTAI VATUATION
*q
U
ti.r, oo lQ.tb
/. D-O
.QD
COMBINATION AppL|CATIONzIERTUT (CAp)
l. Appliconf. to furnish
A. Job Address
B. Legol DescriptionI. exomole-rox lot 100, Lone County Mop Referel2. exompie-Lot l. Block 3, 2nd Addition to Springf
C. Nome, elc. of owner ond construction lender
D. Energy Sources
E. Squore footoge or volu6gie6, a1a.l. exomole-t250 sq. foot house,500 sq. foot goro,- ...............--.-2. exompie-if new proiect, check new-if oddition, <
odd, etc.
F. Euilding permit informotion:
l. exomole-construct single fomily house with on <
goroge
2. exomple-remodel existing goroge into fomily rc
3. eG;Fl-e-convert single fomily residence inro
restouront (chonge of use)
G. Volue of work os defined in Section 303 (o) of the
Slructurol Speciolty Cocle
H. DESIGN TE,AM AND CONTRACTORS
To ovoid design or construction cieloys, Building Di.
Stoff must be oble to contoct oppropriote persons r
design informotion or iob site corrections, etc.
Abbrevioted Plumbing, Mechonicol & Electricol Schedu
A. Except where blenk spoces occur in the description
of the Mechonicol ond Electricol Schedules, the opp
need fill-in only the No. Boxes odiocenf to the oppr
irem(s) to be insrolled
B. Full Plumbing, Mechonicol, ond Electricol Schedule:
ore ovoiloble ot lhe Building Division
'l . To conserve spoce on the permit form the schedr
hove been obbrevioted
2- lf the item(s) to be instolled ore not covered on I
oted schedules you should consult the fuil schedr
C. BUIIDING DIVISION STAFF WILL FILL OUT,ALL FEES
CHARGES ON THE SCHEDUIES I_
Applicont to sign ond dote
Ltt Y r\F 5l,KHY(iFltsLU
Ciry Holl
Springfield, Oregon
Deporlment of Public Works
OFFICIAI RECEIPT
ilo. B 57179
Dote
Received
f L, *+, ,'
l9
l. exomple-heot/electricol ceilinq/or forced oir oo
l. exomote-woter heoler. electricol,,'or solor---_
a,
fi
(
in 4\a
4t,rD
ion
(
4a
Amounl Received Llq ,8t
lrt lorir, .0,
t-^ui*oinio sderune
sk.!roN.ruR!!uLL pirNrEis .,)/."" "^ "r..'
Whenever possible, the initiol opplicotion will be used os o
worksheet only. Where possible, Building Division Sroff will
prepore o typewritten copy ond relurn it to the opplicont ot
lhe time the octuol permit is issued for his signoture.
lV. Fees ond Chorges
Plon check fees ore due ond poyoble ot the time of the opplicotion,
ond no plonr will be processed until these feer ore poid. All
olher fees ond chorges ore due ond poyoble when the permit
is isrued.
V. FOR OFFICE USE ONLY Permit Clerk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Additionol Proiect Informolion:
PLANS REVIEWED BY:
nctme signo ture do!e
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