HomeMy WebLinkAboutPermit Building 1981-8-24
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I INSPECTION LINE L..
721>-37.. ..
I Job Add,,,~l(J A1't(tt '-ff
Il..ol O.",;.tlon /7-e>~ -'3~ 'f ~ 7:1.. See
€illY> OF SPRINGFielD
COMBINATION A'PLlCAflON/PERMIT
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lNFORMAJlON LINE
726-3753
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rkqt, Polk!'''
C,.ee,yc,j e Dr.
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Sq. FIg. Main
Sq. fIg. Accen.
Sq. Ftg. Other
_N@w__AddXAlter.KRep.
____fence_Demo_Chonge I Use
_Olhe,
ENERGY SOURCES:
Heat
Waler Heater
Ranqe _
Value of Work:
Owner
Add.eu
Phon. 7'11-1J' Ie?
Building Permit Info: Describe Work ii.e.. Build Single
Familv Residence With~ Attached GoraCle)
!?.:="P4.lR l);/nA c:.E.z> ST46c..
7Jttrc.- SS. &::-~ -V)l::> $-J>V.k
WEc.l)/bG, J~)C> ;r E ~c.>i:>~ L.
Cons'.uclio" lender
Addren
Phone
DESIGN TEAM
(nome)
(address)
(lies. ria.)
(expires'
(phone no.)
Electrical
*
Primary
Structural
Mechonicol
CONT~ACTORS (nome)
G.n.,oi ])A't/l~ L~WdF/9Y.
(addreul
(lics. no.)
(expires)
(pha"o "'o.l
Plumbina
Electrical
K'o:w &Pt€~4;1,;D €'-~r.
Mecha,..ical
PLUMBING
ELECTR ICAl
MECHANICAL
NO.1
'i p:r;
CHARGE' NO.
FEE i CHARGE I NO.
FEE ! CHARG~
Each linalp. filllurp.
Relacallld building
{new fill. additional}
S.F. R'Hiden~e
(1 both)
SQ: ft.
New circuits. alteratiorls
or e;1ltensions
furnace/bur,..er ta
'~TU's
Appliance'vent
separate
Slationor}' ovap.
cooler
Vent fOil with
sinqlll duct
Vent .system aport from
heating or A.C.
Mechanicol exhaust
hood Qnd d~ct
/
Residenu of
SERVICES
Dualu (1 bOlhl each
Temporary Construction
Additional both
Amps.
Water lervicll
Sewer
Wood stove I healer
Stor.m Sewer
FEEDERS
Heat Pump
Ai, handler to
10.OM CFM
Air hondler 0....'
10.000 CFM
Amps.
ISSUANCE OF PERMIT'
TOTAL CHARGES
TOTAL CHARGES
TOTAL CHARGES
I
WHERE SlATE lAW REQUIRES that the Elect,ical work b. done by the El."'ricol Cont,actor, the electrical portion of this permit shall not bo valid until a
labot ha,; been signed by gn Electrical Contrador and attached to th. electrical panel.
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 performed shall be done in accordance with the Ordinances of the City of Springfield and the laws of the Stat. of Oregon
pertaining to the work described herin, and that NO OCCUPANCY will be made of any structure without the permission gf the Building Oivilion. I further
certify that my regatTatlon 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
:::'f~~,~:.,~::::~~:':D;~~~an~::::~: 0," In ~m.HO<~:N~~~:~RS lJa7!Z7;;'" DATE ffr 2 y -J/ ,
I FOR OFfiCE USE ONLY V
Zone L- q.
Fire Zone
Flood plain
Type/Cansl.~-JI../ .
Bedrooms
O:lotie, J
Unih
t""\ccy load
Occy Group g- ~
0:_. Ftg. Mi:lin
Sq. Ftg. Access
Sq. FIg. Other
Volue
x. Value
,I( Value
TOTAL VALUATION
~e>
plan Clt. Comm/lnd
65%1 Blda Per Fee
Plan (k. Res
30%/8Idq Per Fee
I Systems Development
Charao (1 ..s~:. \
I
+~
PLUMBING PERMIT ~
Charges and
S.<<ho,... I'll
i
I
BUilDING PERMIT
Chargos and
Surcharges
s.
~
s.
00
Fence
"<0
Demo
I Total Comb. Permit
It!). yo
ElECTRICAL PERMIT
Charges and
S~orgu
Sidewalk
AI C Po...ino
TOTAL
"/0. ~e
MECHANICAL PERMIT
Charges and
Surcharges
Curb Cut
~
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COMBINATION APPlICA T10N/P_(CAP)
I. Applica~ to furnish
A. Job Address
B. legal Description
1. examale,tox lot 100. lane County Map Reference 17 03 43
2. example,Lol 1. Block 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. examole.water heater/electrical/or solar
E. Square footage or valuation, etc.
1. ex"ample-1250 sq. foot house. SOO'sq. foot garage
2. example-if riew project, check new~if addition, check
add, etc.
F. Building permit information:
1. exam ole-construct single family house with an attached
garage
2. exomplearemodel existing garage into faniily room
3. exompie-convert single family residence into
restaurant (change of use)
G. Value of work as defined in Section 303 (a) of the
Structu~al 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 inf~rmotion or job site corrections. et~.
II. Abbreviated Plumbing, Mechanical & Electrical Sched~les
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. Tl' 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 cansult the full schedules
C. --BUILDING DIVISION STAFF WILL Fill OUT All FEES AND
CHARGES ON THE SCHEDULES
"
III. Applicant to ,ign 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.
y. FOR OFFICE USE ONLY
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
,
Additional Project Information:
PLANS REVIEWED BY:
nom....
.ignatur,'"
'PERMIT VALIDATION
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Permit CierI-
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