HomeMy WebLinkAboutPermit Building 1980-01-15cot{B I il ,TI APPL I ION RMIT 726-3753
Job Address ZX
Lesal Description 3A OO
EIIERGY SOURCES
Hea t
Ran
llater Heater
Value of tlork:sSo oo
L7
Owner o OU
So. Ftq. l'lain_
!q. Ftg. Access._--_-
ter-Tep.
Sq. Fto. Other
llew Add Al
-Fence Derno Cha nge/ U se
rmit I .€. t
Fami I
u P ueinfr
tii
o: Descri ng eAddress S(I fr+e,Phone
1+t*-l&^Stat-{ Su olru-m.,€
Construction Lender o
o
Addres s Phone
-N.ooo:l
DES I GN TEAI'I name address lics. no.dxoi res rone no
Primary
St ructura I
El ectri cal
l''lechani ca l
CONTRACTORS n arne addres s lics. no.exo'i res dhone no- )Noftllo€El, l' t,ur inn - UAq Harn ?:'tt-tT) +"12-XO 18/^-0501Genera I
I!l umbi ng
El ectrical
l.lechanical
PLUIlBI NG ELECTR I CAL MEC HAN I CAL
FFF CHARGE N0_FFF CHARGF NO FFF CHARGF
Each single fixture Residence of
FTSQ si
furnace/burner to
BTLI
Relocated bui lding
(new fix. additional )
New ci rcui ts al ts
or extensions
Fl oor furnace
and vent
(l bath)
S. F. Res i dence
SERV I C ES
Recessed wal I
Snacp hcatpr ind vonf
Duplex (l bath) each
Additional bath Temporary Constructi on Apol iance vent
seoa ra te
l^later servi ce Change in existing
res i dence
Stationary evap.
cooi er
Sewer multifami ly, conm
Indrrstrial
or Vent fan with
sinole duct
Storm Sewer
Vent systenr apart from
heatino or A.C.
c0r.1r.!. /rND. FEEDERS Mechanical exhaust
hood and duct
I nsta I I /a I ter/ re1 ocate
distrih- feeders \['lood stove/heater 5 )o
0f S.
rssuANcE oF eFRltrT I
TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES t5 co
WHERE STATE L,lt'J REQUIRES that the Electrical work be done by an Electrical Contractor, the electrical portion of this permitshall not be valiC until the label has been signed by an Electrlcal Supervisor and returned to the Bui'lding Division
I HAVE CAREFULLY EXAMINED the completed apolication for Dermit, and do hereb.v certify that al1 i
and correct, and I further certify that any and all work performed shal'l be done-in accoidance withof Springfield and the Laws of the State of 0reoon pertaining to the work described herein, and thatof any structure without the permission of the Building Diviiion. I further certify that m.y registr
Board is in full force and effect as required by ORS 701.055, that if exempt the baiis for ixemptiononly subcontractors and enployees who are in comoliance with oRS 701.055 will be used on this orojec
llAt'1E(please print)oto (. Brrc,k /.tS IGiIATURE DATE ?o
ormation hereon is true
the Ordinances of the City
NC 0CCUPANCY wi I I be made
ation vrith the Builder'sis noted hereon, and thatt.
0)*0^
Ftg
Fto
Ftg
Zone l'la i n Val ue
Fire Zone
Fl ood Pl a'i n
TOTAL VALUATION-
x
XStori es; 0cc.y Group Sq
Uni ts
I Ip
Bed rooms 0ccy Load
Const.
Val ueAcces s.
0the r
Plan Ck. Comm/Ind
65%/B1do Per Fee
Systems Deve'
charqe (1.51'opmentBUILDING PERMIT
Ctrarges anC
Su rcharges Plan Ck. Res
30%/81dq Per Fee
FencePLUi4BING PERMIT
Charges and
Su rcha rges Dgmo
Si dewa I kELECTRICAL PERIlIT
Charges and
Surcha rges Total Cornb. PermitA/C Pavi ng
Curb Cut14ECHANICAL PERMIT
Charges and
Surcharges
O.t {o TOTAL lSGc
0f amps
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job AddressB. Legal Description
l. example- Tax Lot 100, Lane County Map Reference
17 03 43
2. example- Lot 1. Block 3, 2nd Addition toSpringfield EstatesC. Name, etc. of owner and construction lenderD. Energy Sources
PERMIT VALIDATION
Q.p-c+sL63q
rnP t5'oo
trto bc
1. example- heat/2. ExamETe- waterE, Square footage or
el ectrical c 'I or forced air gas t5 bcreeor solaF
valuation,
1. example- 1250 sq. foot house, 500 sq. foot garage2. exampie- if new project, check-new - if addition,
EI'EEI-i-od, etc.F. Bui lding permit information:1. example - construct single family house with an
attached garage
2. example - remodel existing garage into family room3. example - convert single family residence jnto' restaurant (change of use)G. Value of work as defined in Section 303 (a) of theStructural Specia lty CodeH. DESIGN TEAM AND CONTRACTORS
To avoid design or construction delays, Building
Div.ision Staff must be able to contact appropriate
persons regarding design information or job sitecorrections, etc.IL Abbreviated Piumbing, 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. Full Plumbing, Mechanical, and Electrical Schedules
are available at the Building Division1. To conserve space on the permit form the schedules
have been abbreviated2. If the item(s) to be installed are not covered on
the abbreviated schedules you should consult the
ful I schedul esC. BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES0. As noted on the CAP, the label must be delivered to thee'lectrical contractor for signature by his electricalsupervisor. The general contractoris not authorizedto sign the electrical label.III. Applicant to sign and date
Whenever possibie, the initial application will be used as
a worksheet oniy. l,Jhere possibie, Building Division Staffwill prepare a type written copy and return it to theapplicant at the time the actual permit is issued for h.is
si gnature.
IV. Fees and Charges
PIan check fees are due and payable at the t.ime of theapplication, and no plans will be processed until these
fees are paid. All other fees and charges are due and
payable when the permit is issued.
l-(6'8c
V. FOR OFFICE USE ONLY Perm'it Cl erk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPAITCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information :
PLANS REVIEWED BY:
name s'l g nature da te