HomeMy WebLinkAboutPermit Mechanical 1981-10-5
INSPECTION LINE
726-3769
..
CITY OF ~kl"'Gfl&;:D
COMBINATION APPLICATION/PERMIT
.
INFORMATION LINE
726-3753
Job Address
~?mL
f\'C\
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in,
ENERGY SOURCES:
Hea"
Water Heater
Ran~e
Value of Work:
Sq. Ftg. Main
Sq. Ftg. Access.
Sq. Ftg. Other
_New_Add_Alter_Rep.
~l"n(e~Demo_Change/ Us~
( .....'C: Other i")
Building Permit Info: Describe Work (i.e., Build Single
Familv Residence With Attached GaraCle)
Legal Description
O~' 0. JlOA\"\ Nf\\f\O'L"~ IHs\\OX
'-- h ni"J\ - - ~
Ad~'h_n ~ ~-.~ '1<DniD
. 3 J,J'l_'c) \ \
Con1trudian lender V
DESIGN TEAM
(name)
(address)
~\)\t'10() _ (~u('t-ll:hXl
. ,." . 0 )){'If\tinOl '~r\. f\, - J
(PhOn~)
(liu. no.)
(~'ds)
Address
Phane-
Primary
Structural
Electrical
Mechanical
CONTRACTORS
(name)
{address}
(lies. no.)
(expires)
(phone naJ
General
PlumbinR
Electrical
( 'O~f\.\~ ~ f""I LJ
PLUMBING \.) ~ - ---
~ r..Ij/f::J-(jII) I
~ S" l "J \ Qt=:#- 41 DO tt:I~f{z...
ELECTRICAL MECHANICAL
Mechanical
I
SQ. ft.
New circuits, alterations
or extensions
I(JXJ
furnace/ burner to
D,TU's
Appliance vent
separate
Stationary nap.
cooler
Vent fan with
single duct
Vent system apart from
heating or A.C.
Mechanical exhaust
hood and duct
fEE 'C~E
lo.('Y
Residence of
FEE CHARGE NO.
.1
NO.
fEE
CHARGE NO.
_!ach sinq.le fixture
Relocated building
(new fix. additional)
S.F. Residence
(1 both)
SERVICES
Duplex {I bath} each
Temporary Construction
Additional bath
Amps.
Water service
Sewer
Wood stove/h..ater
Storm Sewer
FEEDERS
Heat Pump
Air handler to
10.000 CFM
Air handler over
10,000 CFM
Amps.
TOTAL CHARGES
TOTAL CHARGES
L
lo.m
TOTAL CHARGES
ISSUANCE Of PERMIT I {),vU
! (O.ClO
WHERE STATE LAW REQUIRES that the Eledrical work be done by tb. Electrical Contrador, the electrical portion of this permit sholl not be valid until a
label has bun signed by a~ Electrical Contrador and attached to the eledrieal panel.
I HAVE CAREFUllY EXAMINED the completed application for permit. and do heteby certify that. all information hereon is trult and correct, and I further
certify that any and all work perforrTl4!d sholl 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 herin. and that NO OCCUPANCY will b. made of any structure without the permission of the Building ~ivision. I further
c:ertrfy that my registration with the Builder's Board is in full force and effect 0 s required by ORS 701.055. that if exempt the basis for exemption is noted
hetan, and that only subcontractors and employees who ore in compliance with ORW01.055 will be used on this project.
Basis for Builder's Board-exemption:
NAME (please print) D?'Jl/,j N.
l-IaJ'!",Md SIGNATUREi~~,,-'}?J iLM..ocQ DAT1}f5pl
FOR OFFICEAfE ONLY
Zone Typo/ Canst '1nits Sq. Ftg. Main
fir. Zone ~droom' nccy Load c:.q. Fig. Acclll'
Flood Plain "torie- --;>ccy Group Sq. Ftg. Other
BUILDING PERMIT Plan Ck. Camm/lnd
Charges and 6S%/Bldq Per Fee
Surcharges Plan Ck. Res
30%/ Bldq Per fee
PLUMBING PERMIT
Charges and Fence
Surcharges
Demo
ELECTRICAL PERMIT Ir ?+~
Charges and Sidewalk.
Surcharges
A I C Pavine>
MECHANICAL PERMIT .llO-,- ex)_
Charges and Curb Cut
Surcharges .{ oLl
x Value
x Value
Value
TOTAL VALUATION
Systems Cevelopment
Chorae (, .5%)
Total Comb. Permit
TOTAL
,
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COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job Address
B. Legal Description
1. example-tax lot 100. Lane Caunty 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 ceiling/or forced air qas (
2. example-water heater/electrical/or solar
E. Square footage or valuation, etc.
1. example-1250 sq. foot house, 500 sq. foat 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 ottached
garage
2. example-remodel existing garage into family room
d "
3. example-convert single family resi ence into ,
restaurant (change of use)
G. Value of wo,k as defined in Section 303 (a) af 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 regardir'l ..-.
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 Elect,;cal Schedules, the applicant
need fill-in only the No. Boxes adiacentta the approp,;ate
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 abb
ated schedules you should consult the full schedules
C. BUILDING DIVISION STAFF wiLL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
III. Applicant to sign and date
Whenever possible, the initial application will be used as a
worksheet only. Where pcssible. Building Division Staff will
prepare a typewritten 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 applic
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. ~
V. FOR OFFICE USE ONLY
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Additional Project Information:
PLANS REVIEWED BY:
, nom""
e.ignatur""
.'
'PERMIT VALIDATION
CITY OF SPRINGFIELD
City Hall
Springfiold, Oregon
Department of Public Works
OFFICIAL RECEIPT
If\. .L c::: . No. B 5 7.4 0 5
Dote \\j'r/. ::::::> 1~~ \
Rec'd F=~~t- .d{0fr)
Address~S-~ ~ tstJ
/
Received For:
..- - -
i
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t /j,
\loPO
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(
\ Q \lO~. (f) .(J.-J
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( Amount
( BY
-C'
-,
, ,
Received ~il 04
~1[):j
"H.LTO".TU~"'UU ....'..T.... ' lUG."., 0.. '~"G' .,,,,,.,
Permit Clerk
dale
u/
.....
(
I INSPECTION LINE
726-3769
I Job Address
-.
CITY OF SPIi1NGFIE!~~.
COMBINATION APPU-CATlON'PERMIT
.
INFORMATION LINE
726-3753
JJ
~'.::C'Q. l
f'\'{\ i I\ ,
I ENERGY SOURCES:
Heat
I Water Heater
RanRe
Value of Work:
Sq. Ftg. Main
Sq. Ftg. Access.
Sq. Ftg. Other --
_New_Add_Alter_Rep. 0
_, F",..,(e_Demo_Change/Use
~ .....C 'Other ............ ~
- /J
(B". no.) i.,.(;;' ,) iPhOn~)
Legal Description
I odCl1Qf) "\ Nl \. V)9'L (" ~:pl \ U i.o X
I A~::::-~3n I lJl1\ fl.r'~ \~:*~~.
I {\ n 0 I (.) f:\ . Ul ~ (\ D1U ~.
I .~ ~n\.'c).
Construction lender
I Address
I DESIGN TEAM
I Primary
I Structural
I Electrical
I Mechanical
I CONTRACTORS
Phone
(name)
(address)
~
fJr~
(name)
(address)
(Iics. no.)
(expires)
(phone no.\
G""",,ol
Plumbino
Electrical
,
t'~.l~~(""'lLJ
PLUMBING \) - --
~ r..Ij/f::J-ij/l) 1
8ss1 .,:)\Qt*41~/X'z...
ELECTRICAL MECHANICAL
Mechanical
No.1
FEE
I CHARGE
NO. I
FEE CHARGE
NO.
./
furnace/burner to
~TU's
Appliance vent
separate
Stationary evap.
cooler
Vent fan with
sinRle duct
Vent system aport from
heatinq or A.C.
Mechanicol exhaust
hood and duct
FEE ,t~~E
I 0.1;J-J
Residence of
Each sinRle fixture
Relocated building
(new fix. additional)
S.F. Residence
(1 bath)
I
s~. ft.
New circuits, alterations
or extensions
/ rYr1
/".h~
SERVICES
Duplex (l bath) each
Temporary Construction
Additional bath
Amps.
Water service
Sewer
Wood stove/heater
Storm Sewer
FEEDERS
Heat Pump
Air handler to
10.000 CFM
Air handler over
ID.ODD CFM
Amps.
TOTAL CHARGES
TOTAL CHARGES
In.m
TOTAL CHARGES
ISSUANCE Of PERMIT //) ,DO
/(0.00
WHERE STATE LAW REQUIRES that tho Electrical work be done by tho Eledricol Contrador, tho electrical portion of this permit shall not be yolid until 0
label has bHn signed by a~ Electrical Contractor and attached to the .Iedricol panel.
Basis for Builder's Boarc>>exemption:
NAME (please print) 0 i"J J/ I 'r!
I HA VE CAREFULLY EXAMINED the completed application for permit, and do hereby certify that all information hereon iI true and corred, and I further
certify that any and all work performed shall he done in accordance with the Ordinances of the City of Springfield and the Laws of the State of Oregon
pertaining to the work described herin, and that NO OCCUPANCY 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 iI noted
heron, and that only subcontractors ond employees who ore in compliance with ORS-701.055 will be used on this project.
SIGNATURE [~",,;.lJJ iLN~ h u .Q DAT1}J- f5Pl
IV.
/.J;;Irw...,,>d
fOR OfflCurfE ONLY
Zon~
Fire Zone
Flood Plain
Type/Canst.
l.edrooms
II;.torie--
Units
nccy load
Occy Group
II;.,~. Fig. Main
11;..... Ftg. Access
Sq. Fig. Other
Value
Value
Value
TOTAL VALUATION
x
x
BUILDING PERMIT
Charges and
Surcharges
Plan Ck. Comm/lnd
65%/BldQ Per Fee
Plan Ck. Res
30%/ Bldq Per Fee
Systems Development
Charoe (1.5%\
PLUMBING PERMIT
Charges and
Surcharges
Fe...~iIt
MECHANICAL PERMIT
Charges and
Surcharges
JQ a;:)
.I( )
JW.:..OO_
.f DL/
Demo
Total Comb. Permit
elECTRICAL PERMIT
Charges and
Surcharges
Sidewalk
Ale Pavinll
TOTAL
Ic9()~ur
Curb Cut
"
\i..J1.!
APPLlCATION/PE.T (C~P')
~~..t:~'.:r'~ :,.-C'~f.C .! '\: .J;;'::,~
'\0]'
"ri"~".'>-.r\ '. _' . \
""'We--'" -',-
PERMIT VALIDATION
I",
:--,,'
,-COMBINATION
t -.
\,1, Applicant to furnish
'A. Job Address
:-. -, B. legal Description
1. example-tax lot 100. lane County Map Reference 17 03 43
2. example-lo!'l: Block 3. 2nd Additio'1.toSpringfield Estates.
C. Name, etc. of owner and construction lender .......{ '/./
D. Energy Sources
1. example-heat/electrical ceiling/or forced air gas
2. example-water heater/electrical/or solar
E. i Square footo'ge or valuation, ete: . t' .' ,',
.' 1. exa';'ple-1250 'sq.-fOO! house. 50"0 ~q:fooi garqge
2.. example-if new project; check flew-Jf addition, check
. add, etc. \ . j
F. Building permit information:
1. examole-construct single family house with an attached
garage
2. example-remodel existing garage into 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
St,uctu,al Specialty Code
H, DESIGN TEAM AND CONTRACTORS
To avoid design or construction delays, Building Division
f \ \ '. I Stafl \.must be able to contact appropriate persons regarding
. laesign information or job site corrections, etc.
, ' ,i . ' '. . .
II. Abb,eviated-f\lumbi,;g.,Mechanic~1 & 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. a~'d Electrical Schedules
are available at the Building Oivis!o'1 \\
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 abbrevi-
ated schedules you should consult the full schedules
C. BUILDING DIVISION STAFF Will Fill OUT All FEES AND
CHARGES ON THE SCHEDULES
III. Applicant to sign and dote
Whenever possible, the initial application will be used as a
worksheet only. Whe,e possible. Building Division Staff will
prepare a typewritten 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.
V. FOR OFFICE USE ONLY
, >
\',
PROJECT CONDITIONS TO BE SATISFIED BEFORE:OCc;UPANCY:
.1
. 't h
Additional Project Information:
PLANS REVIEWED BY,
nom"
",ignatur"
. I )
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.J. '
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