HomeMy WebLinkAboutPermit Sewer Connection Record 1981-7-15
I INSPECTION LINE
726-3769
I Job Add,... $(!)(?)7 -
I legal Description L) ~.
I "
I Ow,o' C.,q J/Z. q.- K. L/91?? J?, I
I 0_/ S " Le. L:} ..<: "'3 ; 1/ Building Permit Info: Describe Work (i.e., Build Single
AddresS-:>O 6fJ'- ~ tJ /C. LJ phoneCGJ(T -7b), 3 Fanlily Residence With Attached GarOQe)
I Bt.JGeIl/6 9'7;.,La6" l!ePAI'.&S 7'h ..:5&-a/.ffP~
I Co",,",Ho' l.,do> ~ re"AP ,q/_ .;t:j;o/;;.;~
I Addren Phone I
I OESIGN TEAM
I Primary
.
CITY OF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
.
INFORMATION LINE
726-3753
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n023~32-
I ENERGY SOURCES:
Heat
Water Heater
Range
I Value of Work:
Sq. Fig. Main
Sq. FIg. Access.
Sq. Hg. Olhe"
_New_Add_Alter_Rep.
_Fence_Demo_Chonge/Us8
_Other
'-
t'-
"*
~
~
(nome)
(address)
(lies. no.)
(expires)
(phone no.)
Structural
~
Electrical
Mechanical
CONTRACTORS
(nome)
(address)
(lies. no.l
(expires)
(ahone no.)
General
Plumbino
/1/6
/
Electrical
Mechanical
PLUMBING
ElECrRICAl
MECHANICAL
FEE CHARGE NO. FEE . CHARGE
furnace/burner to
I\TU's
Appliance vent
separate
Stationary evap.
cooler
Vent fan with
single duct
Vent system apart from
heoting or A.C.
Mechanical exhaust
hood and duct
Wood stovelheater
Heat Pumo
Air handler to
10.000 CFM
Air handler over
10,000 CFM
,.
"
,
NO.
FEE
CHARGE NO.
Residence of
Each sinQle fixture
Relocated building
(new fix. additional)
S.F. Residence
(1 both)
~.... ft.
New circuits, alterations
or extensions
SERVICES
Duplex (I bath) each
Temporary Construction
Additional bath
Amps.
Water service
Sewer
Storm Sewer
FEEDERS
Amps.
ISSUANCE OF PERMIT
TOTAL CHARGES
/fA1 hf=E
TOTAL CHARGES
TOTAL CHARGES
WHERE STATE LAW REQUIRES that the Eledrical work be done by the Electrical Contrador, the electrical portion of this permit shall not be valid until a
label has been signed by an Electrical Contrador and attached to the eledrical panel..... ............
I HA VE CAREFUllY EXAMINED the completed application for permit, and do hereby certify that all inf~f\'O~c.gn is true and correct, and I further
certify that any and all work performed shall be done in occordance with the Ordinances of the City of Springfield a~nd 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 ond effect as required by ORS 701.055, that if exempt the basis for exemption is noted
heron, and that only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project.
Ba.;. fo' Builde,', Boa,d ex:mp,;o,. ~~ I (K) L4f-
NAME (plea.e p';",) ('I. ~.h."v-d ? Lc..lAAl,...\r SIGNATURE ~(Ar DATE7jitS/~1
FOR OFFICE USE ONLY ~ ., J .
Zone Type/ Canst. Units C;:". Ftg. Main
Fire Zone Bedroom- nccy load Sq. Ftg. Access
Flood Plain ",torie~ Occy Group Sq. Fig. Other
BUILDING PERMIT Plan Ck. Comm/lnd
Chorges and 65%/BldR Per Fee
Surcharges Plan Ck. Res
30%/ BldR Per Fee
PLUMBING PERMIT
Charges and Fence
Surcharges
Demo
ELECTRICAL PERMIT
Charges and Sidewalk
Surcharges
Alc Povinn
MECHANICAL PERMIT
Chargos and Curb Cut
Surchorges --------
x Value
x Value
x Value
TOTAL VALUATIOI"'
Systems Development
Charae CT.5%l
Total Comb. Permit
TOTAL
-i::."
'.
A
C.
COMBINATION
.
APPLICATION/PERMIT ,(CAP)
I. Applicant to furnish
A. Jab Address
B. Legal Description
1.. example,tax lot 100, Lane County Map Reference 17 03 43
2. example-Lot 1. Black 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 gas,
2. example-wa.ter;'heater/e1ectrica1!or solar
E. Square footage or v.aluation, etc.
1. example,1250 sq. faat hause, 500 sq. faat 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 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
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 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 date
Whenever possible, the initial application will be used as a
worksheet only. Where 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 OCCUPANCY:
Additional Project Information:
PLAN5 REVIEWED BY,
nom'"'
..ignatur'"'
.
PERMIT VALIDATION
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Permit Clerl~
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