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Home My WebLink AboutPermit Backflow Test 1985-6-26 .m/l/(L . CITY OF SPRINGFIELD COMBINATION APPLICATION/PERMIT ---- EIIERGY SOURCES: Heat !~ater Heater Ranqe 10lll<-l INFORlIATION Ll,'< 726-37S3 Sq. Ftg. 1.lain ~q. Ftg. Access. Sq. Ftg. Other Ilew Add A lIer ~ep. --Fence Demo Change/Use Other - - ,~ '-'l u \) . I IrlSPECTION LINE 726-3769 Job Address 1;07/ legal Description Owner /t / /I r _ _,1 (jYjUf ~r7 ~~ Pho~e I Q,2~-9I;;() ValUE of Hork: Address Builriina Permit Info: Describe Work(i.e., Build Single Famil~ Residence With Attached Gar~e) ~ 4~ /:rliA'~'/ ~..-rj//';:' / Construction lender Address Ut~lliN rl:.AI~ (name) Phone (address) flies. no.) {exniresl (ohane no. ~ i' Primary Structural Electrical Mechanical CONTRACTORS (name I (addrpss) (l ics. nn. \ (pxo;rps) (ohnnp no.) Genera 1 Plumbina fU{j/lL~ /,;)t, -f6 $LO E1 ectrica 1 Hechan;cal PLUIIBING ELECTRICAL MECHANICAL ~ FFF cHARC,F ~L Each single fixture Residence of ~~~ I rl:iARG.E..-1:!Q.....1 SQ. FT. furnace/burner to BTU's n.~ 1...c.l:iARGE. Relocated building (new fix. additional) New circuits alts. or extensions Floor furnace and vent S.F. Residence (] bath 1 Duplex (1 bath) each Additional bath SERVICES Recessed wall ~n~rp hp~tpr ~nrl vpnt Sewer jTempOrary Construction I'Change in existing resjrlenrp Imultifamily, comm. or Industrial 10f ICOI1I.I./IND. FEEOERS 1 Install/alter/relocate rli,trih_ fpprlpr, Of amps.1 amps. Appliance vent c;.~oarate Stationary evap. cooler Vent fan with sinole-duct Vent system apart from I heatino or A.C. Mechanical exhaust hoorl ilnd durt ~Iater service Storm Sewer Wood stove/heater /0 ,at> ,40 TOTAL CHARGES /o.tID TOTAL CHARGES TOTAL CHARGES WHERE STATE L'\l~ REQUIRES that the Electrical work be done by an. 'Electrical Contractor. the electrical portion of this pel"lilit shall not be vali~ until the label has been signed by an Electrical Supervisor and returned to the Building Division ~p~~ :~~ ~ vf" 9-- 41t> ISSUANCF OF PFR'11T I HAVE CAREFULLY EXM1INED the completed application for permit, and do hereby certify that all information hereon is true and correct. and I further certify that any and all work oerfonmed 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 IlO 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 ORS 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 701.055 will be used on this project. IWIE(p1ease print) S1eCJ~ NU jp__ Zone Fi re Zone Flood Plain Tyoe/Const. Bedrooms Stories Units Occy Load Occy Group SIG:IATURE .)6---U-f... H~_ FOr. OFFICE USE OfI'LY Sq. Ftg. f1ain ,x Sq. Ft9. Access x Sq. Ft9. Other x OATEt--- ;Jt ---is-- Value Value Value TOTAL VALUATION BUILDING PER~1lT Charges and Surcharges Plan Ck. Comm/lnd 65%/Rldo Ppr F'pe ~----------- Plan Ck. R-es 30%/B1da Per Fee ______.JJ2...'_~ Fence _ '16 Demo ___________J S1dew~lk I A/C Paving ____________, Curb Cut I Systems Development CharQe O.5~) PLU'1BlNG PERMIT Charges and Surcha rges ELECTRICAL PERI~IT Cha rges and Surcharges 11ECHANICAL PERMIT Charges and Surcharges I Total Comb. Permit I TOTAL I /O;-j0 -, - . COMBINATION APPLICATION/PERMIT (CAP) PERMIT VALIDATION I. Applicant to furnish A. Job Address B. Legal Description 1. example- Tax Lot 100, Lane County Map Reference II oj 43 2. example- Lot I. Block 3, 2nd Addition to Springtield Estates C. Name, etc. of owner and construction lender D. Energy Sources 1. example- heat/electrical ceilinq/or forced air Qas 2. examole- waterheater/electrical/or solar E. Square footage or valuation, etc. ------ I. example- 1250 sq. foot house, 500 sq. foot garage 2. example- if new project. check-new - if addition, check add, etc. F. Building pennit information: 1. examele - construct single family house with an attached garage 2. examole - 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 TEAf1 AND CONTRACTORS To avoid design or construction delays. Building Division Staff must be able to contact appropriate persons regarding design information or jab 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 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 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/h ~~()/c FI- P ftcf?9~ G ~d0 <'f5" .- V. FOR OFFICE USE ONLY Permit Cl erk tftiiit / PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY: Permit applicant exempt from registration with the Builder's Board because: Additional Project Information: a . PLANS REVIEWED BY: name signature date .