HomeMy WebLinkAboutPermit Building 1991-1-4
IINSP.ECTION LINE
726-3769
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CITY U, SPRINGFIELD
COMBINATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
l~ater Heater
I
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INFOro1ATION LINE
726-3753
Sq. Ftg. 1,Iain
~q, Ftg. Access.
Sq. Ftg. Other
New Add Alter Rep.
--Fence Demo Change/Use
Other- -
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Owner'
Job Address b 330' Mtclll""l S T ~;;I') Y2
Legal Description l7-tJ.;)-,3t/-...i'-/- 03003
, 3a . Range
o 300/ J 0 'ValuE of Hork'
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I BuildinQ Permit Info: Oeser,be Work(Le.,
,'-Iv" J '7 VI' Phone Farnil y Residence \~ith Attached Garaoe \
?</6-/lf61
Address
LS~;. L, 0... Ie
~o Box
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Build Single
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Construction Lender.
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Address
UlS IIjN IlAl1
(name I
Phone
(address 1
flies. no.)
(exo;res)
(ohane no. I
Primary
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Structural
Electrical
Mechanical
CDNTRACTORS
Plumbina
lnamel
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f' /J~"" t> >-. ,nJI>,!. Co
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{addr~ss ,
fl ics. no. \
(exo;res)
(ohane no. 1
Electrical
KIll",
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3 170 ?J. II!! ~
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Genera 1
~lechan;ca'
PLU'1BING
ELECTRICAL
MECHANICAL
NO.
FEE CHARr.F NO
<r> CHAJlGE. ..llO
~F"~ .cHAR..GL
IOtJ!2 15""
SQ. FT.
furnace/burner to
BTU's
Each single fixture
Residence of
Relocated building
(new fix. additional)
New circuits a1t5.
or extensions
Floor furnace
and vent
S.F. Residence
(1 bath)
Duplex (1 bath) each
Additional bath
SERVICES
Recessed wall
~n~r~ ~p~tpr ~~rl vpnt
Storm Sewer
Of
COffi~./IND. FEEDERS
Install/alter/relocate
~i~trib_ fppder,
llmps.
Appliance vent
!;:po#l ra te
Stationary evap.
cooler
Vent fan with
d n01 educt
Vent system apart from
heatino or A.C.
MeChanical exhaust
hood and dud
Wood stove/heater
Sewer
Temporary Construction
Change in existing
rpsjrlJ'Ju'p
multifamily, camm. or
Indll"trial
~Ia ter serv; ce
Of
amps.
ISSUANCE OF PFR!1IT
TOTAL CHARGES
WHERE STATE LAH REQUIRES
shall not be vali~ until the
TOTAL CHARGES
TOTAL CHARGES
that the Electrical work be done by an.'Electrical Contractor, the electrical portion of this pemit
label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFUllY EXAMINED the completed application for permit, and do here~v certify that all information hereon is true
and correct, and I further certify that any and all work oerformed 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 HO OCCUPArKY will be made
of any structure without the permission of the Building Division. I further certify that my registration with the Builderts
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
only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project.
NAi,IE(please print)d~-,-. /7~ SIGIIATURE b~n"1/.J /P"'}",;;/? 7"""
Far. OFFICE USE ONLY
Sq. Ftg. t1ain
Sq. Ft9. Access
Sq, Ftg. Other
DATE /- "'/-7'/
Zone
Fi re Zone
Flood Plain
Type/Const,
Bedrooms
Stories
Units
Occy Load
Occy Group
x
Value
Value
Value
x
x
TOTAL VALUATION
BUILDING PERflIT
Charges anC;
Surcharges
:3 'D .)'0 Plan Ck, Corrrn/Ind
____________~/Rldo Pj'r FpfI
I 93 Plan Ck, Res
, 30%/BI do Per Fee
1-00
"j . Fence
------------
, 7.1 D,mo
'Sidewalk
2- 5. 03
Syste~s Develop~t
Charqe (1.5~) "
N/A
PLW1BING PERMIT
Charges and
Surcharges
ELECTRICAL PERIHT
Cha rges and
Surcha rges
~ MECHANICAL PERMIT
~ Charges and
l" Surcharges
/
A/C Paving
/fjtL/ep~/IOT C<>/l'e.5
. .0 If!, /"{2
Total Comb. Permit
0~
Curb Cut
TOTAL
~'1 z 1
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.
.
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
1. Appl icant to furnish
A. Job Address
B. Legal Description
1. example- Tax Lot 100, Lane County Map Reference
II U3 43
2. example- Lot 1. Block 3, 2nd Addition to
spr,ngtield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. example- heat/electrical ceilinq/or forced air qas
2. exam~le- waterheater/electrlcal/or solar
E. Square footage or valuation, etc. ------
1. example- 1250 sq. foot house, SOD 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
a ttached 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 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.
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. BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
O. 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. ---
111. Applicant to sign and date
Whenever possible, the initial application will b~ 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
signature.
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.
fJJ 07V-
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1(1)[)~2-
V. FOR OFFICE USE ONLY
Permi t Cl erk
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
.
PLANS REVIEWED BY:
name
signature
!i, date
,\:
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.,
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