HomeMy WebLinkAboutPermit Building 1986-3-28 (2)
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B1SPE'TlON LINE
726-3 69
Job Address .3:3 20 M-AtA'
Legal Descriptlon 17-t)z..!/..~J.
CITY UF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
'. I ElIERGY SOURCES:
Heat
Water Heater
Ranoe
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IHfORJtATJON l.L~l:. "
726-3753
Sq. ftg. Hain
!q. ftg. Access.
Sq. ftg. Other
--11ew__Add~lter-"~ep.
Fence Demo Change/Use
Other- --
.<;;r.
"2~
'FL.Er.et-
ValUE of Wor~ "'0
r 3c;)CO I
Bull6ino Penmit Info: Describe Work(i.e..
Fa~ilv nesidence With Attached C,araoe}
Build Single
Address
Owner -.Jf)<:,qtf,' 6UJuA.'
Phone
Construction lender
Address
UI:.~H.iN fl:.Ar.,
Primary
Structural
Electrical
Mechanical
CONTRACTORS
General
~w A:)bc..
Plumbina
Electrical
~1E!chanieal
NO.
(name)
Phone
(address\
~r;.,~P?,r !iM- I1tf/f~.tJ'J';j-
hi'F; MIli2:UA-tL: Eb:rrl A:fA<H- : .lJtitM<L I
~At'~" 'l
flies. no.l rexnires) (ohone no.)
(name)
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"WL
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1'" "I~lf1irc; !'In..'
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{FJhnnp fin 1
(addressl
(PYI"';""'c:.'
PLUIIBING
I
cCL J:l:lARG.E ~In
~~~ rl-l
MECHANICAL
FFF
Each Single flxture
furnace/burner to
BTU's
Relocated building
(new fix. additional)
S.F. Residence
II both)
Duplex (1 bath) each
Additlonal bath
Water service
Sewer
"'0'
Storm Sewer ~ I
2.2.!
Floor furnace
and vent
/ ~ ~~~~~~a"rt ~~nt
"e'!.
Temporary Construction
Change in existing
rp~ i (h~.nrp
multifamily. comm. or
TJ'lrlnc;;tri;tl
Appliance vent
c:.pn;t r~tp
St.ationary evap.
r-""lpr
Vent-fan with
c:"jnnlp rfll,.1'
Vent system apart from
heatina or A.C.
Mechanical exhaust
~C'(\~ ;tnd rfllr-t
Wood stove/heater
3,,0
!
.2LJ~
1 !J()
Of
amps.
VAMU/J1 I>;f''/(/U?c'.
CO~1./IND. FEEDERS
Install/alter/relocate
rHe1'..;" f".pripre
Of
6A~ rJll"l,c!?,
?~
amps.
tSSUANCE OF PFRltlT
~7!!!. TOTAL CHARGES 22 S"o TOTAL CHARGES /11/,v ,
that the Electrical work be done by an 'Electrical Contractor. the electrical portion of this
label has been signed by an Electrical Superv~sor and returned to the. Building Division.
TOTAL CHARGES !H11.//iNt(M
WHERE STATE L~W REQUIRES
shall not be valij untl1 the
15""
pemit
1 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 oerformed shall be done in accordance with the Ordinances of the City
of Springfield and the Laws'of the State of Ore~on pertaining to the work described herein, and that 110 OCCUPAIlCY 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 ~ereon. and that
only subcontractors and employees who are in compliance with ORS 7Ql.055 will b~ used on this project.
IWIE(please print)
Zone c:: ~
Fire Zone
Flood Plain
BUILDING PERNIT
Charges anC:
Surcharges
PLur~BING PERMIT
Charges and
Surcharges
ELECTRICAL PERmT
Cha rges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
Tyoe/Const.~~
Bedrooms
Storl es /
SIGIlATURE
FOR OFFICE USE 0111 Y
Sq. Ftg. ltain
Sq. Ftg; Access
So. Ftg. Other .IFn>'?At:f
x
x
DATE
I
Units
Occy Load
Occy Group..B-2
Value
Value
Va 1 ue :s~...?...., <;!Z
TOTAL VALUATlON
x
:3 <2> -s-a Plan Ck. Conm/lnd
_______-:;~-_-~/BJ1o P.rr fpp
/ t;.,... Plan Ck. Res
.. 30%/Bldo Per Fee
___~~_~~_~_ Fence
/,/0
22. .S-o
------------
.~ t'
____L~~~___
,bD
Systems Development
CharQe (1. 5~) , .
DC/IllO
.Sidewalk
AlC pavlng?~~1
I Curb' Cut I
I I
iJ8. S~
ITota1 Comb. Permit
I TOTAL Ill! 6.1'1
.
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job Address
B. legal Oescription
1. examole- Tax lot 100, lane County Map Reference
II UJ 4J
2. example- lot I. Block 3. 2nd Addition to
~prlngtield Estates
C. Name. etc. of owner and construction lender
O. Energy Sources
1. examole- heat/electrical ceiling/or forced air ad
2. examole- waterheater/electrlcalJor solar'
E. Square footage or valuation, etc. ------
1. examole- 1250 sq. foot house. 500 sq. foot garage
2. examp_l~- if new project, check-new.- if addition,
check. add. etc.
F. Building pennit information: .
1. example - construct single fa~11y house with an
attached garllge - - t.' . iIi. . \:..
2. examole - remodel existing garage into family rao
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. OESIGN TEAM AND CONTRACTORS
To avoid design or construction delays, Building ,~ ..
Division Staff must be able to contact appropriatet.
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 appli~ant need fill-in only the No. Boxes adjacen
to the appropriate item(s) to be installed
8. Full Plumbing, Mechanical. and Electrical Schedules
are available at the Building Division
1. To conserve space on the permit form the schedule:
have been abbreviated
2. If the item(s) to be installed are not covered on
the ab~reviated schedules you should consult the
full schedules
C. BUilDING DIVISION STAFF WIll FILL OUT All FEES ANO
CHARGES ON THE SCHEOUlES
D. As noted on the CAP, the label must be delivered to tl
electrical contractor for signature by his electrical
supervisor. The general contractor is.not authorized
to sign the electrical label. -
Ill. Applicant to sign and date
Whenever possible. the initial application will b~ used a~
a worksheet only. Where possible. Building Division Staf1
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
t
PERMIT VALIDATION
/j) &/ to
CITY OF SPRINGFIELD
City Hall
Sprlngftald, Orogon
Department 01 Public Works
OFFICIAL RECEIPT
( No. B 66180
(Date i ,q - ?1, .- 19~
( Rec'dFro~~h~ (,.1000.. ~\..LCOQ.y
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Address
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$' / '7 (P. /1
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Amount Received
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AUTHORlZEO SIGNATURE
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
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/)Mt~ M?E= ~,!,q'1"-'rJ"" ,." ,t=M1.rr 6~.7~ .
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name .#~/~~ signaturep~LJ L. m~
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'date 'f /-:2~ flU.
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