HomeMy WebLinkAboutPermit Building 1995-09-28SPRINGFIELD
RESIDENTIAI, PERMIT APPTICATION
CITY OF SPRINGFIELD
COMMT'NITY SERVICES DIVISION
BUII,DING SAFETY
Page 1
ilob Number: 951455A
225 North Fifth Street
Springfield, OR 97477
Location of Proposed Work: 8057 THURSTON RD
Assessors t"tap #: L7023602
Lot: Block:
Office:
Inspection Line:
726 -37 59
725 -37 69
Tax Lot #: 00206
Subdivision:
CITY OF SPilNGFIEI^O, ONEGON
Owner: ELAINA FISHER
Address: 8067 THURSTON RD
Describe Work: RESIDENTIAL ADDITION
Phone #: 747-4876
ciry/srate/zi-p: SPRTNGFIELD, OR 97478
NEW
QUAD AREA: 5RNE
-- OFFICE USE .-
LAND USE: 1111
To requests an inspection, call the 24 hour recording aL 726-3769.
A11 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 ---
FOOTING - After trenches are excavated.
FOITNDATION - After forms are erected but prior to concrete placement.
WATER LINE - Prior to fill-ing Erench.
SAI{ITARY SEWER LINE - Prior to filling trench.
ELECTRICAL SERVICE - Must be approved to obtain permanent power.
FINAL BUILDING - I{hen all required inspections have been approved and
the building is complete.
ftem
Main
Garage
Total Value
Building Permit Fee
Surcharge/admin
TOTAI, FEE
--- BUILDING PERMIT ---
Square Feet x $/Square Feet Val-ue
800.00
0.00
800.00
15.00
L.20
(A)L6.20
PLI'I{BTNG PERMIT ---
Item
MINIMUM PERMIT FEE
Plumbing Permit
Surcharge/admin
TOTAL CIIARGE (c)
Fee
15.00
15.00
L.20
L5.20
--- MISCELLAI{EOUS PERMITS
Surcharge/edmin
SYSTEMS DEVELOPMENT
ELECTRICAL PERMIT
TOTAIJ MISCEIJIJAIIEOUS PERMITS
0
LL4
54
00
94
00
158.94(E)
20L.34(Excluding Electrical )
un1eEs otherwiae noted
--- TOTAI, AIITOI,MT DUE ---
(A, B, C, D, and E combined)
SPRINGFIELD
,Job Number: 951456A
ATT OF SPRINGFIELD, ONEGON
Page 2
--- BUII,DING VAI,UE, PI,AIiI CHECK ATiID BUII.DING PERMIT ---
This permit is granted on the express condition t.hat the said construction
shal], in all respects, conform Eo the Ordinance adopted by the City of
Springfield., including Ehe Development Code, regulating the construction and
use of buildings, and may be suspended or revoked at any time upon violation
of any provisions of said ordinances.
-.- A.DDITIONAL COMMEMTS ---
By signature, I Etaue and agree, that I have carefully e
t.he completed application and do hereby eerEify that all
xamined
informaEion 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 Ehe Laws of the State of Oregon pertaining to the work described herein,
and thaE NO OCCUPANCY will be made of any structure without permission of the
Community Services Division, Building Safety. I furt,her certify that only
contractors and employees who are in compliance wiEh ORS 701.055 will be
used on this project.
I further agree to ensure that all reguired inspections are requested at the
proper Lime, that each address is readable from the sEreet, 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 construction.
/r,/*{
ignature Date
--- VALIDATION ---
Receipt Number:
Date Paid:
th3qL8lq5
.cDt .otp
rc1
,q
7
q
Q-
*,N\fol\)\
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t
Amount Received
Received By
1 Addition is to be connected to existing structure by covered walkway or porch.
Walkway/porch is to be completed within njnety (90) days of Temporary 0ccupancy.
Until 1ega1 partition of the property is completed, structure is approved as
single family residence only.
2
B CTS
utceo e ^
ff\D0,*-,
SPRINGFIELO q'RESIDENTIAL
PERMIT APPLICATION
lnspections: 726-3769
Office: 726-3759
LOCATION OF PROPOSED WORK:
ASSESSORS MAP:
LOT:
h,
JOB NUMBER
225 Fifth Street
Springfield, Oregon 97 477
TAX LOT:
BLOCK:SUBDIVISION
PHONE
zlPa-7/n STATE:
OWNER:
ADDRESS
CITY:
NEW -- FIEMODEL ADDITION DEMOLISH s111ss^- /y' Z Wa l&
DESCRIBE WORK
EXPI RES PHON EADDRESS
L:
CONTRACTOR'S NAME
CONST.
CONTRACTOR #
GENERAL:
PLUMBING
MECHANICA
ELECTRICAL:
r OF BDFIMS:
_ OFFICE USE -
LAND IJSE:
ZONING CODE:
FLOOD PLAIN
WATER HEATER:
E OF UNITS:
RANGE:
SECONDARY HEAT:
SQUARE FOOTAGE:
OUAD AREA:
# OF BLDGS
OCCY GROUP:
* OF STORIES:
CONSTR. TYPE:
HEAT SOURCE:
To request an inspection, you rriust call 726-3769. This is a24hour recording. All inspections requested before 7:00 a.m' wlll be
made the same working day, inspections requested after 7:00 a.m. will be made the following work day.
REOUIRED INSPECTIONS
Temporary Electric It=.(ough Mechanicat - Prior toL-l 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.
al Mechanical - When all
mechanical work is complete.
Fooling - After trenches are
excavated,Fireplace - Prior to facing
materials and f raming lnsp.
Final Building - When all
required inspections have been
approved and building is
completed.Masonry - Steel location, bond
beams, grouting.
Other
Foundation - After forms are
erected but prior to concrete
placement.Wall/Ceiling lnsulation - Prior to
cover.
Underground Plumbing - Prior
to f illing trench.[--l orywall - Prior to taping
MOBILE HOME INSPE TIONS
Underlloor Plumbing/ Mechanical
- Prior to insulation or decking.Wood Stove - After installation.
Post and Beam - Prior to floor
insulation or decking.tnseit - Aite:' firepiace 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
irench.Electrical Conneclion - When
blocking, set-up, and plumbing
inspections have been approved
and the home is connected to
the servlce panel.
Storm 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
Slreet 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.
a
7?7- 4? 74,
q- "78
*227 ,e)
Er
E
E
r
E
E
E
E
E
I Framing - Prior to cover.
tl
E
tlE
Lot faces
Lot sq. ftg.
Lot coverage
Topography
Total height
Lot Type
-
lnterior
-
Corner
-
Panhandle
-
Cul-de-sac
Set l(s IS THE PROPOSED WOFIK IN THE
HISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTER?
-
lf yes, this application must be signed
and approved by the Historical
Coordinator prior to permit issuance.
APPROVED:
P.L,GARHSE ACC
N
S
E
VALUE
(A)
X $/SO. FT.
Total Value
Building Permit Fee
State Surcharge
Total Fee
BUILDING PERMIT
ITEM SQ. FT.
Main
Garage
Carport
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
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
upon violation of any provisions of said ordinances.
Receipt Number:-
Plans Reviewed By Date
Plan Check Fee:
Date Paid
Fleceived By
SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
Systems Development Charge is due on all undeveloped
properties within the City limits which are being improved.
ITEM
Fixtures
Residential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
FEE
(c)
N0
FT.
FT.
FT.
PLUMBING PERMIT
Plumbing Permit
State Surcharge
Total Charge
ADDITTONAL COMMENTS
Wood Stove/ lnsert/ Fireplace Unit
Dryer Vent
(D)
NoVent Fan
Mechanical Permit
lssuance
State Surcharge
Total Permit
MECHANICAL PERMIT
Fu rnace
Exhaust Hood By signature, I state and agree, that I have caref ully examined
the completed application and do hereby certlfy that all
information hereon is true and correct, and I f urther 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 contiactors and employees who
are in compliance with ORS 701.055 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 ls located at the front
of the property, and the approved set of plans will remain
natu re
Date
ron.on the s;te at all tirncs d'-;rin
MISCELLANEOUS PERMITS
Mobile Home
State lssuance
State Surcharge
Sidewalk
-
ft
Curbcut
--
ft
Demolition
State Surcharge
Total Miscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, D, and E Combined)
D
I
VALIDATION
RECEIPT NUMBE
DATE PAID
AMOUNT REC
RECEIVED BY
I
AIa4U
OFEGO'VCITY OF SPR
1 ON
Permi ts are non-transferable and exPire
if vork is not started vithin 180 days
of issuance or if vork is suspended for
L80 days.
2.COMRACTOR INSTALI.,ATION
EIect I Contractor
Address
Ci ty Phone
Supervisor Li s ber
Expi ra t ion.te
Cons tr tr. Number
Exp at ion Date
ture of Supervising Electric
0vners Name
Address
Ci ty Phone
OVNER ALI..ATION
The installation is being made on
property f ovn vhich is not intended
for sa1e, Iease or rent.
mttted has the {
speci{ic land use
ELECTRICAL PERI{IT APPLICATION
Ci ty Job Nurnber
COHPLETE FEE SCEEDTIIJ BELOV
A Nev Residential-Single or
Multi-Family per dwelling unit.
Service Included:ftems Cost
$ 8s.00
SPrrINGFIELD
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereof
Each Manuf'd Home- or
Modular Dvelling
Sertice or Feeder
J t..i.rt not requiia
225 FIFTH STREET
SPRINGFTELD, OREGbN 974
INSPECIION REQUEST:.. 72
OFFICE: 726-3759'
-fg --15
A&horized
Sum
$ 1s.00
s 0040
B Services or Feeders
Installation, Alterations
or Relocation:
200 amps or less \
20L amps to 400 amPs _
40L amps to 600 amPs
-
601 amps to 1000 amps-
Over L000 amps/volts
Reconnect 0n1y
Temporary Services or Feeders
Installation, Alteration or Relocation
200 amps''or less $ 40.00
over 4b1 to 6oo amps
-
$ Bo.oo
0ver 600 amps or lbOO voTts see 'Bu a65iE-
Branch Circuits
Nev, Alteration or Extension Per Pane1 '
s s0.00
s 60.00
s100. 00
$130.00
s300.00
$ 40.00
s
c
D
One Circuit $ 35.00
Each Additional
Circuit or vith Service
or Feeder Permit $ 2-00
E. Miscellaneous (Service/feeder not included)
-Each installation
Pump or irrigation
Sign/0ut1ine Light ing_
Limited Energy/Res
Limited Energy/Comm
SUBTOTAL OF ABOVE
5Z State Surcharge
32 Administrative Fee
TOTAI
$40
$40
$20
$36
00
00
00
00Onryers Signature
fur,^V4,
5
DATE:
RECETVED B
@
'!Ft-+ 11r:
t.'.
1. LOCATION OFnotn INSTALI,ATION
approv al
Zonin
225 FTFTH STREET
SPRTNGFTELD, OREG0N 97477::4' --
INSPECTION REQIIESTI 726-17.69l;.;.i tr'r,-rn,''
OFFICE: 726-3759
SPRIi.GFTELE'
ELECTRICAI PERHIT APPLICATION
b Nunber Q=t tll n(o
3. COHPI,ETE FEE SCMDI'LE BELOII
A Nev Residential-Single or
Multi-Family per dvelling unit.
Service Included:Items Cost
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereo f
Eaeh Manuf'd Home or
Modular Dvelling
Servi.ce or Feeder
s 8s.00
s 15.00
s 40.00
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/vo1ts
Reconnect 0n1y
$ s0.00
s 60.00
s100.00
s130. 00
s300. 00
$ 40.00
c
200 amps or less
201, amps to 400 amps
-Over 40L to 600 amps
Over 600 amps or 1000-l6l-[s
--lra ,, u ,ldI
LEGAL DESCRIPTION
JOB DESCRIPTION
Permits are non-transferable and expire
if vork is not started vithin 180 days
of issuance or if vork is suspended for
180 days.
2. CONTRACTOR INSTALI.ATION ONLY
ElectricaL contractor 0riE$0li ILEIIRIC S[RYitE
Address \>,--, (5o*-.a.,
ss&s43-wt
6cl.r -s
Sum
Ci ty on
Expiration Date /O ' Q(u
Constr Contr. llumber clo4G C-
Expiration Date q -qLD
re of Supervising Electrician
Temporary Services or Feeders
Installation, Alteration or Relocation
Supervi sor icense Number
Signafu
7l*011*,'r '1
SUBTOTAL OF ABOVE
52 State Surcharge
32 Administrative Fee
TOTAL
40.00
55.00
80.00
ee *8" aEF
-<-
s
s
$
s
Ovners
Address
Ci Phone
OgNER INSTALLATION
The installation is beihg made on
property f ovn vhich is not intended
for sale, lease or rent.
Ovners Signature:
DATE:ID- lo -
D. Branch Circuits
Nev, Alteration or Extension Per Panel
one circuit I S 35.00 1lf.}"
Each Additional
Circuit or vith Service
or Feeder Permit S 2.00
E. Miscellaneous (Service/feeder not included)
5 He{.-
-Each installation
Pump or irrigation S
Sign/Out1ine Lighting- S
Limited Energy/Res $
Limited Energy/Comm S
40.00
40.00
20.00
36.00
C'TY OF OFEGSIU
RECEIVED
5
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funr, &o-,
04 Pil wlnato
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full
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u
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EIBNI vt. FtsuER, M.s.
Oregon Teacher Certification
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4/nd.a/rld.
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Handicapped Learner II . . t
Wr" ioL-$dq
Home 747-4876 Cellular 954-1352
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TENTATIYE PARTITION MAP FOR
ELEI'{A FISHER,
N.W. t/4, SEC. 36, T.175., R.zYr., W.M.
SPRINGFIEI,I, IANE COANTY, OREGON
AUGUST 4, 1995
SCAI-E 1' = 100'
I ,o 6o
ZONNG:
LDR . LOA D€'IS7Y R6SDEI{II4L
TE PROPERrY fO IIE YEST 6 ZOA€O L'X, II€
frffiRty to ,)€ Easr ,s zot€o cRto. ft€ PRe€Rff
70 I}€ SOiJTH 'S L.o.R, AAO @'O. TI€ PROPERfY
TO Ir€
^rof,rH
E ZO €0 Eru
DASTNC USE:
SN6LE FAI.I-Y
PI.OODIIAY:
SASED OrV FW DAI!. COr,f{UVrv PA|€.L Na. 4t559t
0390 c. DECE^/EER 18. 1945. InS PROPERIY rS il
zot€ c Ato 6, ,ELL o(/I8DE fE tOO YEAR FLO@yaf.
IE PRoPERTY TO TT€
'VORTH
6 PARIIALIY N ZAt€ A"
SOIAR STATEMENT:
nrs DEv€toPr€Nr r'€rs saaR accEss 5IAfDAR06 P6R
clry oF spRryc.FElo otvttde*rm cox J4.ato til t.
r4 l
OINER E APPUCANT:
ELEM At F6r€A
8067 ft,.Rglo|l RoaD
sPR \(jF€LO. 6 37476
DESCRIPTION:
t7-o2-36-2 fL ?O5
EIEYATIONS BASED ON:
OTY 6 ffitJG.'ELD OAIW
LEGEND
+
o PRoPEBTv coRr{ER A
-* OERHEAD POv€RLtlE ts
URAAN CROYIH SAAD^RY
NETRO PLI.N DESIGNITIONT
LDR . LO' O€NgIY RESO€I/rtrL
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VICINITY MAP t tooo'
u
PBOJECA:
TENIArIVE PARTITION MAP
TAX MAP 17-02-36-2
TAX LOT 206
CUE}{l:
ELENA M. FISHER
A067 THURSTON ROAO
sPRrN6FlEL0, OR 9747A
DlrRTNSIONS
IOGI PAR& W
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From
of
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A.M.
P.M.
Area Code Number Ext.
Fax
Area Code Number
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Please callI@ilVre@@rE@IE@EEIEI@
III
Signed
Ouill Corporation. Be-order Number 7-92001
\
RFSIDENTIAL
PERMIT APPLICATION
lnspections: 726.3769
Qf fice; 726.3759
\
LOCATION OF PROPOSED WOFIK:
SPR rxcrrelE
zfr,fus7 7i*.ffaaJ E
JOB NUMBER
225 Fif tlr Street
Springfl etcJ, Oregon g7477
ASSESSOBS MAP:17-oL--oL
TAX LOT;7e 6.
LOT:BLOCK:
PHONE;
STATE:ZIP:
7u <,t
7
CITY:
OWNEB:
ADDRESS:
ADDITION DEMOLISH OTHER
OESCBIBE WORI(:
NEw X BEMoDEL
ADDFESS
l)ONEIRES . PH
a-Z/e, atl
CONTBACTOR'S NAMI-:
G EN EBAL:
PLUMBING:
MECHANICAL:
ELECTRICAL:
CONST.
CONTRACTOR /
- OFFICE USE -
LAND USE:
,f OF UNITS:
QUAD AREA: -
I OF BLDGS:
FLOOD PLAIN:
ZONING CODE
SECONDARY HEAT:
SOUARE FOOTAGE;
, OF BDRMS:
OCCY GROUP:
E OF STORIES;
CONSTR. TYPE:
HEAT SOUBCE:
WATER HEATER:___RANGE:
Fool
To rcquest an rnspection, you must cail 726.376g. Thrs rs a 24 hourmade thc sante worklng day, lnspections rcquested aftor 7;00 a,m.
rccordlng. All lnspecilons requosted before 7:00 a,mwlll bo macle the followlng worl( day.
REOUIRED TNSPECTIONS
l--l Tornporary Etectric
Slto lnspcction - To be macloalter excavatlon, but prlor toSettlnO forllts.
Foundallon - n ftor forms areerocled but prlor to concreloplace,nont.
U n der Plumbing/ Electrical/| - Prlor to cover.ca
- A,ter trenches are
led.
Masonry - Steel locatlon, bonclbeams, grouilng,
Rough Mechanlcal - prlor tocover.
Rough Eloctrlcal - prlor tocovcr.
Electrlcal Servlce - Must beapproved to obtaln permanent
clectrlcal power.
Flroplace - prlor to faclngmaterlals and framlng lnsfl
Framlng - prlor to cover.
Wall/Colllng lnsulallon - prlor to
I-_l FInat ptumbtng - When ail
-
plumblng worl( ls complete.
[-_| Flnat Eloctrlcal - When ail'- electrlcal work ls complote.
Flnal Mscharrlcal - When allmechanlcal work ls complete,
Flnal Bulldlng - Whon altrequlred lnspecilons have beenapproved and bulldlng lscompteted,
wlll be
Othor
cover,
[-l Underground plumblno - priorr-J to flllliq rrcnch [-l Drywall - prtor ro raptng.
Underlloor plumblng / Mcchanlcal
- Prlor to lnsulatlon or clecklng.
Post and Boanv. - prlor to lloorlnsulallon or docklng.
MOBILE HOME INSPE TIONS
Plumblng Connoctlons - Whenhomo has been connected towater and sewer.
Floor lnsulatlon - prlor todecklng,
Rough Plurnbing - Prlor to
cover.
Wood Stovo - After lnstallatlon.
Curbcut & Approach - Afterlorms are erected bUl prior toplacomont of concrctc.
Streel Troos - When all roqulredtroes aro plantod.
[--l tnsert - After flreptace approval
-
and lnstallailon ol unlt.
[--l Btocktng and Sot.Up - When ail
-
blocklng ls complete.
l-_] Sarritary Scwer - prior ro ililtng.J lrench.
Storm Sewer - prior to fllllngtrench.
Sldewalk & Drlveway - Af terexcavatlon ls completo, lormsand sub.base materlal ln place.
Electrlcal Connoclion - Whenblocklng, set.up, and plumblnglnspections have beon approvedand the home ls connected lothe servlce panel,Water Llne - Prlor to f llling
trench.Fenco - When completed.
Flnal - Alter all requiredInspectlons are approved andporchos, sklrtlng, decks, andventlng havo been lnstallod.
tl
E
Lot faces
Lot sq. ftg.
Lot coverage
Topography
Total helght
Lot Typc
-
lnterlor
-
Corner
-
Panhandle
-
Cul.de.sac
. HE PROPOSED WORK tN THE
HISTORICAL DISTRICT, OR ON
THE HISTORICAL FIEGISTER?
-
lf yes, thls applicatlon must be slgned
and approved by the Historical
Coordinator prior to permit issuance.
APT)ROVED
P.L.HSE GAR ACC
N
S
E
VALUE
(A)
I
X $/SO, FT,
Total Valuo
BUILDING PERMIT
ITEM SO, FT.
Maln
Garago
Carport
Building Permit Fee
State Surcharge
Total Fee
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
Thls permlt ls granted on the cxpress condition that the said
constructlon shall, ln all respects, confortn to the Ordinance
adopted by lhc City of Spring(lclcl , includlng the
Development Code, regulating the coostruction and use of
bulldlngs, and may be suspended or revoked at any time
upon vlolation of any provisions of said ordinances.
Recel pt Nurnbcr:---.. -
Date Pald
Received By
7 Plan Check Fee
SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
Systems Developmcnt Charge ls due on all undeveloped
propertles wlthln tlrc City linrits whiclr are being lmproved.
Resldentlal Bath(s)
Sanltary Sewer
Water
Storm Sewer
Moblle Home
PERMIT
FEE
N0
(c)
FT.
Plumblng Permlt
Stato Surcharge
Total Charge
PLUMBING
ITEM
Flx t u res
ADDITIONAL COMMENTS
Wood Stove/ lnsert/ Fl roplace Unlt
Dryer Vent
(D)
N0Vent Fan
Mechanlcal Permlt
lssuance
State Surcharge
Total Permlt
MECHANICAL PERMIT
Furnacg
Exhaust Hood By slgnature, I state and agree, that I have carcf ully examlned
the completed appllcation and do hereby certlfy that all
lnformatlon hereon ls true and correct, and I f urther cerilfy
that any and all work performed shall be done in accordance
wlth the Ordinances of the City of Sprlngf ietd, and the Laws
of the Stato ol Orcgon pertalnlng to thc work described
heroln, and that NO OCCUPANCY wiil be macJe of any
structure wlthout perrnission of the Butldirrg Safety Dlvislon.
I further certlfy that only contractors and employees who
are ln compllance with ORS 701.05S wlll be used on thls
prolec t.
I further agree to ensurc that all requlrecl Inspectjons are
requested at the propor tlme, that cach address ls readable
from tho street, lhat the permlt card ls located at the f ront
he approved set of plans wlll remaln
s durin con s
,,
Slgnature
Date
ction
of the propert
on the slte at
MISCELLANEOUS PERMITS
Moblle Home
State lssuance
State Surcharge
Sldewalk
-
ft
Curbcut ' (,
Demolltlon
State Surcharge
Total Mlscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding electrlcal)
(A, B, C, D, and E Comblned)
VALIDATION:
\
BECEIPT NUM R
DATE PAID
AMOUNT RECEIV
BECEIVED BY
\}Ntr
!tr Ptans Prcvl-ewccl-By-Date
FT.
-
FT.
F Pr-r Tr F PT S r-:r-rNsl TPI lr--TnN F1!a! !;61U7r:!t-,
tNt{)t7'.
v,/
Authorizctlon to Proceed AEreement
Page 4.
8E}-iitiE srGt',ING THiS AGREDIIENT, pt,EASE READ TND UIIDERSTAIID THE I'lDrrl'lrlJG 0F t;'"t:ir
PAJ1AGRAYH OF THIS 6GREEHEI{T. IT A}'F'EC'[S YUUR INIERDSTS 1I{ THE PP'OPERTY A]JO' J
.r'rjE uvEr{T oF DEFAUI,T, 1T pLAcEs you PEES0NALLT AT Rr st( At{t) THn suBJEcr PROI'LF"
..,t.Ht5K 0F FORECLOSURE !'UN C0S'fS AND EXPENSES INCUITJIf,D BY THE CITY IN Eiifolc]i.
THE TERHS OF THIS AGREEHETIT. IN ?HE EVENT THAT YOU DO ITOI'U}IDERSTA}JD AltY'I :hHi
0i coHpruoNs oF THrS AGREEHEN?, PLEASE SEEK ANy Lr,l(:AL oR oursrDE oPtllIoNS Y"r'
HAY"DESIRE.
A}PLICANT('ITY
City of Springfield i
Nt ltsyrContractor
Building Offrclal Business l{ame IL
Add ress Eo(, / \-lt0R (J IJ
CC Registration {l'j6
T"A,I'ID/PROPTSTT OIINER (s)
T/VE HAVE READ THE ABOYE AUTEORIZATIOI{ TO PROCEED AGREEHDI'M.1/VE UNDERS]AN.]
UIIA'I T? EXPRESSES A}TD THE RESPONSIBILITIES IT FLACES UPON US AS THE
LA]TD/PROPERT Y O\NER.q. I/UE BE BOUND TIY ALL TERI'IS AI{D COI{PI'IIOIiS OT 'I HF:
AGREEHEI'JT.
llamo
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i i'l=i:::: l;F Ct-iY ATTDi'i1'ju-\'
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