HomeMy WebLinkAboutPermit Building 1984-1-1
i '1" INSPECTION LItlE"
. 726-3769 .
Job Address
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Description\'" O'L ~(.\ ~ \
legal
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CITY Of SPRiNGfIELD
COMBIIIATION APPLICATION/PERMIT
ElIERGY SOURCES:
Heat
Hater Heater
Range
ValuE of Hork: e~r.
'f. K6Clo 0"+-:-
BuildinQ Permit Info: Describe Work(i.e'f
Family nesidence With Attached Garaoe)
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INFOR/1ATION LINt
726-3753
Sq. Ftg. t']ain
~q. Ftg. Access.
Sq. Ftg. Other
tlew Add A I ter Pep.
--Fence Demo Change/Use
Other- -
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Owner (:L A f1 ",-r." K A pTi ~ 't C lwl'-ZC h
Address r-. 5 h L{ ~A .A" o...J s T ~[(:f P~-c;"c;t-:
Construction lender
Address
Ut~JliN II:.At1
(namelrtAlll -C--J.
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Primary
Structura 1
AciA
<; -r; ,.4
Electrical
Mechanical
CONTRACTORS
~15
_ Phone
r<'LL/}Tr ,r] (address) ,_
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Build Single
r;iJ/~~ I~J'" tl<:.. A.tIri
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BUD t<; !J,o ~ <; 7,,!l,A 0(<1
"":.t:l../ IUA", tJrlics. no.l (exo{f'p~)
ClFIJGo k, 'it.,
St1(>I\I;~<< ~;>
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(ohane no. \
11~,,'-rc..~
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STUM<A_AJu.A
5Au<!.~~
Gif./..i 1" :,...cltlu:...
Genera 1
InameJ..i1..6():T. iSllf T,<"7 raddress1J., ->(,1/ n01lplics. nn.1
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(pxoires)
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(ohOl'lP nn ,
P1umbino
Electrical
flechanica1
PlUtlB I NG
NO. I I FEE [HARGF
\ Each single fixture 5.00
Relocated building
(new fix. additional)
IS.F. Residence
r1 bath1
IOUP1ex (1 bath) each
IAdditional bath
IWater service
I Sewer
I Storm Sewer
k\.~,tM.\...... ~e.~
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ELECTRICAL
NO t
Residence of
SQ. FT.
New circuits a1ts.
\ or extensions
SERVICES
A
~
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MECHANICAL
I H~ nl~ NO_ I
l-..ff.L 1...cHARG..E..
furnac~/burner to
BTU's
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B-t':Chs<::o
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Floor furnace
and vent
Recessed wall
~n~..p hp~tpr ~nrl
VP11t
Iremporary Construction
IChange in existing
rp'So.i1pJ1('~
Imultifamily. COI111l. or
InrllJc;tl~i<ll
10f
ICOMfI./IND. FEEDERS
I Install/alter/relocate
ni~tr;h fppder,
Of amps. I
IW.IE(please print)
20ne 'l... "-
Fire Zone -
Flood Plain -
TVDe/Const\l- \. 'N~
Bedrooms
Stories 2. - ~\Cj:.
?()~~-
'eo
- ---'- ~-'-~--
.<<:'0
Units
Occy load
OCCV Group ~-:":::>
Plan Ck. Comm/Ind
65%/B1d~ Per Fee
Plan Ck. lies
30%/BldQ Per Fee
I Fence
I Demo
I Sidewalk
I A/C Pavi ng
Curb Cut
Appliance vent
seoar<lte
Stationary evap.
cooler
I Vent fan with
sinale dlJct
I Vent system apart from
heating or A C.
I Mechanical exhaust
hood <lnd duct
I ~Jood stove/heater I I
I#~T ?~p Its ~
k~"""EL""":Z:> 6t.-~""~
.J;;.~ R t'.Atp..,.~ "'S"-~A ~
I I ISSUANCE OF PFR!m~~/'7
\. ~_~ TOTAL CHARG~S-'-
Electrical Contractor, the electrical portion of this pe~it
Supervisor and returned to the Building Division
amps.l
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I HAVE CAREFULLY EXAMINED the completed aprlication 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 OCCUPAUCY 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 ons 701.055. that if exempt the basis for exemption is noted hereon. and that
only subcontractors and employees who are in compliance with OP.S 7Ql.055 will be used on this project.
SIGtlATURE
FOP. OFFICE USE mIL Y
Sq. Ftg.
Sq. Ft9.
Sq. Ftg.
DATE
r1ain
Access6?'?-.
Other
x
x
Value
Value
Value
BUIlDIflG PERfIlT
Charges and
Surcharges
PlUt1BING PERMIT
Charges and
Surcharges
l\
ELECTRICAL PERr~IT
Charges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
x
TOT^l VALUATION
(O?- rq' ,....-.a::r Systems Development
./' Rr.:::2/~C? Charqe (J.5n "
<jO"
Irota1 Comb. Permit
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I TOTAL
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'Qt 40
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
Ill.
I. Applicant to furnish
A. Job Address
B. legal Description
I. ~xample- Tax lot 100. lane County Map Reference
17 U3 43
2. examele- lot I. Block 3, 2nd Addition to
Sprlngtield Estates
C. Name. etc. of owner and construction lender
O. Energy Sources
1. examole- heat/electrical ceilinq/or forced air qas
2. example- waterheater/electrical/or solar
E. Square footage or valuation, etc. -
I. example- 12S0 sq. foot house, SOO sq. foot garage
2. example- if new project. check new - if addition.
check add. etc.
F. Building pennit information:
1. example - construct single family house with an
attached garage
2. exam~le - remodel existing garage into family room
3. exam~le - 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 TEM4 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.
II. 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. BUIlDI~G 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
signa ture.
IV. 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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V. FOR OFFICE USE ONLY
Permit Clerk
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
~D~ ~ t\~~O'LG:.",~ ~P: ~\\...\~r--:~~~e- (')C.t-,,~~~Y
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
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PLANS REVIEWED BY:
nam~\,:">"'S.. ?t \~~~
SignatuV...r'-~\l'''' ~
d~te"\.- 0...- <?-. ~
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