HomeMy WebLinkAboutPermit Building 1984-5-23
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-COMBINATION APPLICATION/PERMIT (CAP)_-
II.
I. Applicant to 'furnish
A.JobAddress
B'. Legal Description
. 1. examp 1 e- Tax Lot 100, Lane County Map Reference
, 17 03 43
2. example- Lot 1. Block 3, 2nd Addition to
Springfield Estates,
C. Name, etc. of owner and construction lender
D.' Energy Sources
,1. example- heat/electrical ceilinq/or' forced air qas
2.' example- waterheater/electrical/or solar"
E. Square footage or valuation, etc. ,-
I. example- 1250 sq. foot house, 500 sq. foot garage
2. example- if new project, check new - if addition,
check add, etc.
F. Building permit information:
1. example - construct single family house with an
attached garage . , '
2. example - remodel existing garageintb family room
3. example - convert single family residence into
restaurant (change of use ) -.
G. Value of work as defined in Section 303 (a) of the
Structural Specialty Code ,
H. DESIGN TEAM AND CONTRACTORS
To avoid design or construction delays, Building
Division Staff must be able to contact appropriate
persons regarding design information or job site
corrections, etc.
Abbreviated Plumbing, Mechanical, & Electrical Schedules
A. Except where blank spaces occur in the description
portion of the Mechanical and Electrical Schedules,
the applicant need fill-in only the No. Boxes adjacent
to the appropriate item(s) to be installed
B. Full Plumbing, Mechanical, and Electrical, Schedules
are available at the Building Division
1. To conserve space on the permit form the schedules
. have been abbreviated '
2. If the item(s) to be installed are 'not covered on
the abbreviated schedules you should consult the
full schedules
C. BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
D. As noted on the CAP, the label must be delivered to the
electrical contractor for signature by his electrical
supervisor. The general contractor is ,not authorized
'to sign the electrical label. -
Applicant to sign and date
Whenever possible, the initial application will be used as
a worksheet only. Where possible, Building Division Staff
will prepare a type written copy and return it to the
applicant at the time the actual permit is issued for his
signatvre.
Fees and Charges
Plan check fees are due and payable at the time of the
application, 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.
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PERMIT VAll DATION
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IV.
V. FOR OFFICE USE ONLY
Permit Clerk
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
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Permit applicant exempt from registration with the Builderls Board because':
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Additional Project Information:
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PLANS REVIEWED BY:
name ~H.r:7>~-LSignature~~...~~
date ~-2 :J--8 Y
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I INSPECTION LINE
726-3769 .
.. CITY OF SPRINGFIELD .
CQtlBINATlON APPLICATION/PERMIT
ErlERGY SOURCES:
Heat
. l~ater Heater
RanC)e_____:..__'~_,_____..,_ ___
, . , . . ....... "..... ".-- ... ........,
ValuE ~Hork: '__
Owner ?/9t! /HC J?:#1 ~J-c/a;{)Dds-..:&(!, ~~~htO:'3{?t-:..-.
, . Bui1riino Permlt Info: Describe Work(i,e., Build Single
Address <.7..?:<;;:? ~n-t-eJ- C I "PI Phone.7v?-BJ9; Familv nesidence With Attached Garaoe)
,V?;.;r::: /d ~~r"p .M~~:U..,Jc:..A~ ~~F/C:~
Construction Lender }?"/'-P/......A::"". ./ A:5'50~/4T~ &V/hG_
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&dP ~T~ /M;e>fl?OV~ll"E"",~.
(lics. no.) (exllires) (ohone no. J
INFORtlATlON UNt .
726-3753
Sq. Ftg. f.lain
~q. Ftg; Access.
Sq. Ftg. Other
XJlew_Add_Alter ~qep. .
Fence Demo Change/Use
-Other - -
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Job Address ?tJO.;Ai. (?;;( # S""~LC~
Legal Description /7."2-3/-::Z1 ~ ~t:.. ~~
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Address
DES I GN TEAr1
(name)
Phone
(address)
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Primary
Structura" .
Electrical
Mechanical
CONTRACTORS (name)
General JJlod tI //7/Ir-e '/t')'B/j- r./:Je.
EN tVr It/,?)1,-(S' .
S-~,p ~ ~M fl>C!.i-;..I(l
(~~r;!rF'~~ )
,,(p.
(lies. no,) (exoires)
o.e~(w.. Ct 'b '77(#S-
(ohone no. )
..~.5-60~O
P1umbino
Electrical
Evye/lc3
TOTAL CHARGES
WHERE STATE L~W REQUIRES
shall not be valid until the
. *?S, Dc TOTAL CHARGES ~. - TOTAL CHARGES
that the Electrical work be done by an, Electrical Contractor, the electrical portion of this permit
label has been signed by an Electrical Supervisor and returned to the Building Division
BUILDING PER~1IT
Charges and
~r;:;rpes
PLUt1BING PERMIT
Charges and
Surcharges
I HAVE CAREFULLY EXAMINED the completed application for permit, 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 OCCUPAIICY will be made,
of any structure without the permission of the Building Division. I further certify that my registration with 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
"'y "bo"t"ot", ,'d "",y", wh, '" ;, oom,l;"o, with OR' 701.055 wfl1 bo '~hf' ,"j,ot. __ .
NAI-1E(please print) ttJ/?/~N, D, /9 SIGNATURE ~ ~ DATE..s' -/8-8r
FO~ OFFICE USE ONLY I
So. Ftg. 11ain ~F,IC/~~(U~a1ue~~.-'
Sq. Ftg. Access x Value .
Sq. Ftg. Other.l'.AY/h6. x . Val~e ~~r~<,.-
r~ 5Pc:::. ?ul'/~~ TOTAL VALUATION.3~S"~. -
. ./ e:" OD Plan Ck. COIllll1/Ind ~ d 7'L- Systems Development ~4~. ~.-
~ ~~ 65%/B1do Per Ff'P co C7' i7 Charqe (1.5%) . . ~, co ;7f..o-'
--- - ------ PlanCk. Res --
30%/B1 do Per Fee
____'95= - I Fence
:3. S~ I D~R1o
2~. -0 I Sidewalk
-------~ 80 -, A/C pavingc11fS~.1
I Curb Cut I
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Zone M.#
Fire Zone
Type/Const. ~?IV
Bedrooms
Flood Plain
Stories
I
Units
Occy Load
Occy Group~--~
ELECTRICAL PERlm
Cha rges and
Surcharges
3:Z.~
Total Comb. Permit
2/6 60
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MECHANICAL PERMIT
Charges and
Surcharges
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TOTAL
$37.85
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