HomeMy WebLinkAboutPermit Building 1983-7-11
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I INSPECTION LINE
726-3769
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CITY Uf SPRINGfIELD
COMBIIIATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
Hater Heater
Range
ValuE ~Fiy).OO
BuilriinQ P~it Info: Describe Work(i~e., Build Single
Family Residence With Attached Garaae1
\ ~" i\. (')f>Il. -, ffi () ~ 6 -(\0~ C(IL -
U - 0
INFOR/IATION 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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Job Address 6'\ 5[) <....X'{\t\ ".{\ ,,-^htoo t, I
Legal Description \ l f\? ~ \ O() fY\U iYJ I
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Owne~fi1)to ,~ON)l.Q,~ \.\.C1t).
Address(:J.,\~, ~\('\9..'f'\ (~> . \~hone
con~~d~ J(;)r.J QI4-'l
Address
Ul:.~ Hit{ n.N'
(namel
Phone
(address)
flies. no.)
(exoiresl
(ohane no.
Primary
A
'If(
Structural
Electrical
Mechanical
CONTRACTORS lname!
Genera\ i ) ~Ji\.~
(address)
(1 i,.,c no.)
(pxoirp~)
(ononp no
Plumbina
Electrical
~1echanical
PLUIIBI NG
ELECTRICAL
MECHANICAL
NO.1
-----lEach single fixture
I Relocated building
(new fix. additional)
Is.F. Residence
(j bath)
IDuplex (1 bath) each
IAdditional bath
I ~Ia ter servi ce
1 Sewer
Istorm Sewer
I FEE I fHARGF
Nn I
Residence of
I ~I-.C..I::i8RG.E. NO I
I ~~~
Irl-l~
SQ. FT.
furnace/burner to
BTU's
//
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
Sl1i'1rp hPi'lTP" :Inri \,,onT
Of
amps.
Appl iance vent
<;pni'lr:lt,o
Stationary evap.
rnnlpr
Vent "fan with
sinale duct
Vent system apart from
heatinq or A.C.
Mechanical exhaust
hood nnd dud
Temporary Construction
Change in existing
rpsjrlJ'}1l"P
multifamily, comm. or
Tnduc:tri;d
COMI,!. IIND. FEEDERS
Install/alter/relocate
(tictri!, fPPrlpl"c:,
Wood stove/heater
Of
amps.
ISSUANCE OF PFRMIT
TOTAL CHARGE5 TOTAL CHARGES TOTAL CHARGES
WHERE STATE L\!I 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 permit, and do hereby certify that all information hereon is true
and correct. and I further certify that any and all work Derformed 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 rw OCCUPArKY 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.
Zone
Fire Zone
Flood Plain
Tyoe/Const.
Bedrooms
Stories
Units
Occy Load
Occy Group
SIGIlATUR
FOn OFFICEfD5E O~LY
~g.r1ain
Sq. FtD. Access
Sq, Ftg. Other
U- ~(~ DATEXd 8'3
NM1E(please prin
!\.
x Value
x Value
x Value
TOTAL VALUATION
BUILDING PER/tIT _d4t?-- Plan Ck. ConmlI nd
Charges and 65%/Bldo Pj'r Fpe
Surcharges .(..0 Plan Ck, Res
30%/Bldo Per Fee
PLUI1BING PERMIT Fence
Charges and ------------
Surcharges D~mo
ELECTRICAL PERI~IT I'Sldewa I k
Charges and ------------ I A/C Paving
Surcharges
MECHANICAL PERMIT I Curb Cut
Charges and ------------
Surcharges I
Systems Development
Charoe (1.5%) ,
TOTAL
d4 q <oj
Total Comb. Permit
.
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job Address
B. legal Description
I. example- Tax lot 100, lane County Map Reference
II 03 43
2. example- lot I. Block 3, 2nd Addition to
Springtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. exa~'e- heat/electrical ceiling/or forced air qas
2. exa~~le- waterheater/electrlcal/or solar
E. Square footage or valuation, etc. -----
I. examole- 1250 sq. foot house, 500 sq. foot garage
2. example- if new project. check-new - if addition,
check. add, etc.
F. Building permit information:
1. examele - construct single family house with an
attached 9ar~ge
2. examele - remodel existing garage into family room
3. exa~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
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. FOR OFFICE USE ONLY
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
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PERMIT VALIDATION
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o~tl)83
WLU-, %llL.
-::::=-
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Permit
clerk(1WCL)
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
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STATE FORESTR" DEPARTMENT
EAsTERN LANE DISTRICT
..... 3150 MAIN STREEl; I""
SPRINGFIELD, OREGON V7477 '
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