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Home My WebLink AboutPermit Miscellaneous 1979-10-9 ~) . CITY UF SPRINGFIELD COMBINATION APPLICATION/PERMIT EilERGY SOURCES: Heat \-later Heater Range Valu€ of Work: y_ eo Phone ~?&:j1~~ Buildino Permit Info: Describe Work(i.e., . ,~~~ Family Residence With Attached Garaoe) f:47i>,I.{IHc:.. LGr 'hY'he- . INFORlIATION UNo 726-3753 Sq. Ftg. 1'1ain ~q. Ftg. Access. So. Ftg. Other New Add Alter Rep. -Fence Demo Change/Use Other - - UJ - I~ 'i INSPECTION LINE , 726-3769 Job Address 4971- Legal Description J), x(~J Owner '...J~ Address c:;J/ d (, / Cohstruction lender I ~/ GI~U. Build Single Phone-- (address) ~' Address DESIGN TEAM t"-S:-..,~ (name) ~--U;(- v' ~ -, (lies. no.) (exoiresl (ohone no.) Primary Structural Electrical Mechanical CONTRACTORS (namel ~~5 (addrF!ss) (lieo;. nn.) (pxoi rp5:' (onnnp nn 1 General #X~h< r_ , ~,/I"-W~k~,Q (IV. ,~~t!!fN4/i~. --=~--/s/ ~ Plumbino E1 ectri ca 1 ~1echanical PLUI,1BING ELECTRICAL MECHANICAL NO. FFF rHARGf N~ FFF IJ:I!ABliE. NO" CEL CHARGf Each single fixture Residence of SQ. FT, furnace/burner to BTU's Relocated building (new fix. additional) S.F. Residence (1 bath) IDuplex (1 bath) each Additional bath New circuits alts. or extensions Floor furnace and vent SERVICES Recessed wall ~n~rp hp~tpr ~nrl vpnt Sewer Temporary Construction Change in existi~g r~'jid~flcP Imultifamily, camm. or Indu-;;tria1 IOf amps.1 ICO~1./IND, FEEDERS I Ilnstall/alter/relocate I di~tr;h. fppdpr~ Of amps.1 I App 1 i ance vent ~E1Daratp I S'tationary evap. coolElr I Vent fan with ~inalEl duct Vent system apart from heatina or A.C. Mechanical exhaust hood and dud. Wood stove/heater Water service . Storm Sewer ISSUANCf OF PFRrHT TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES WHERE STATE L,\l~ REQUIRES that the Electrical work be done by an, Electrical Contractor. the electrical portion of this permit shall not be vali1 until the label has been signed by an Electrical Supervisor and returned to the Building ~ivision I HAVE CAREFULLY EXAMINED the completed application for germit. and do hereby 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 Oref]on pertaining to the work described herein, and that NO OCCl!PAf~CY will be made of any structure without the permission of the Building Division, 1 further certify that my registration with the Builder's Board is in full force and effect as required by ons 70~,055. that if exempt the basis for exemption is noted hereon, and that only subcontractors and employees who are in compl iance with OP.S 7111.055 will be used on this prOject. NAI'lE(please pr,in~V t7! rs;, / c),-r/V G./i/ll/e~S!GrlATUR'Y~J~ 0i2:-.. '2ID~~ j()-'l-7'; & FCrr.-o'frjc( USE DIlLY Sq. Ftg, Sq. Ftg. Sq. Ftg. IJ Zone Fire Zone Flood Plain Tyoe/Const. Bedrooms Stories Units Occy Load Occy Group '-;.0 x90 ~.- t1ain Access Other x Value Value Value x TOTAL VALUATION BUILDING PERI1lT Plan n. ConmlI nd Charges and ------------ 65i/Bldo Ppr Fpp Surcharges Plan Ck, Res 30ilBldo Per Fee PLUI1BING PERMIT Fence Charges and ------------ Surcha rges D(l101o ELECTRICAL PERrm 'Sidewalk Cha rges and ------------ Surcharges AIC Paving MECHANICAL PERMIT Curb Cut Charges and ------------ Surcharges Systems Development Charqe (J,5~) t.~.., :>~W~ ~~C7"OA; . /~....o :?~.- Total Comb. Permit TOTAL ~ I~ 'I. 0.... - . COMBINATION APPLICATION/PERMIT (CAP) I. Applicant to furnish A. Job Address B. Legal Description I. examole- Tax Lot 100, Lane County Map Reference 11 03 43 2. exam~le- Lot 1. Block 3, 2nd Addition to' Springtield Estates ' " C. Name, etc. of owner and construction lender D, Energy Sources 1. example- heat/electrical ceilin,Q/or forced air Qas 2. example- waterheater/electrlcal/or solar E. Square footage or valuation, etc. - 1. exam~le- 1250 SQ. foot house, 500 sq. foot garage 2. example- if new project, check new. if addition, eneck add, etc. F. Building permit information: 1. examole - construct single family house with an attached garage 2. examole - remodel existing garage into family room 3. examole - 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 ~ivision 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. - 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 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. V. FOR OFFICE USE ONLY PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY: . PERMIT VALIDATION PCW~lt.cO< SifJr rn ScuJ-Q.Y 1 ~ - 12~ (X) crJ '10 : c - '1 i ~ Permi t Cl erk r1 , . Permit .appl icant exempt from registration with the Builder's Board because: Additional Project Information: . ~.... ~ PLANS REVIEWED BY: name signature , date J