HomeMy WebLinkAboutPermit Building 1983-9-19
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I INSPECTION LIIIE.
726-3769
Job Address \C":O \ ~(\ \ 0 0t, .
Legal De<cription \l()~~~4-\ -C5~
CITY UF SPRINuFIELD
COMBIIIATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
Hater Heater
Range
Phone
JNFORllATION liNt
726-37S3
Sq. Ftq. 1.lain ro
~q. Ftg. Access. ~~
Sq. Ft9, Other V'"
Ilew Add Alter Pep. E)
-Fence Demo Change/Use
Vjt' ~~lc:A.00 -Other- -
Bui16ino ~rmit Info: Desc~lbe Work(i.e., Build Single ~"'\,
Familv nesidence With Attached Garaoel ~
l ~Q--!o")\'~b C\'PI'<'f\ffio1\.1' ioQ.
~
Owner .0\ L~
Address 2- ~() 'i\..,: ~. ~.
~Orl (\)e l')4~-~~
Constructio), Leiltler I
Address
UtSluN IEAI1
(name)
Primary
Structural
Electrical
Mechanical
CONTRACTORS
Genera 1 ~ ,
Phone
(address)
(lies. no.)
(exoires)
(ohone no.
M
~
l'
l1ic5. no.) !pxoires) (ohnnp nn, \
~l~ ~l ith ...,.1) l()::~l.\\~
(rP,~44q1<" )
Jnamel (address)
;~.~ '~~'~RJ aru\On
, \-
Plumbina
Electrical
~'echani ca 1
PLUllBI NG
....lliL,1 ' FEE 'CHARGF
lEaCh single fixture
IRelocated building
(new fix. additional)
Is.F. Residence
(l bathl
!DuPlex (1 bath) each
IAdditional bath
I ~Iater servi ce
Sewer
Storm Sewer
ELECTRICAL
I
- ~ MECHANICAL
I r\.ll1R.G..E Nn I ~~J:'
"--fw:nace/burner to
BTU's
I ru"liiG.E.
Nn '
I ~H
Residence of
SQ. FT.
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
~n~rp hp~tpr ~nn vpnt
Temporary Construction
Change in existing
rf'<;' i n_encp
Imultifamily, COTllll. or
Tnnll<:.trial
IOf amps
Ico~4./IND. FEEDERS
IInstall/alter/relocate
rli<:.trih_ fpprlpr<:.
IOf amps.1
I
I
I
Appliance vent
<;'PDar~tp
Stationary evap.
cooler
I Vent fan with
c:inole duct
I' Vent system apart from
, heatinq or A r:
I Mechanical exhaust
hood and duct
I Wood stove/heater
I
I
I
ISSUANCE OF PFRt1IT
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 pernit
shall not be vali~ until the label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXNlINED 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 Oregon pertaining to the work described herein, and that NO OCCUPAIKY 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.
NAME(please print) rj",.,J ;T /00.../ C.V" SIGN^TURE~O iAJA OATE 9-/'1-'13
FOR OFF I CE USE OIIL Y ,
Zone Type/Const. Units Sq. Ftg. riain x Value
Fire Zone Bedrooms Occy Load Sq. Ftg. Access x Value
Flood Plain Stories Occy Group Sq. Ftg. Other x Value
BUILOING PERI.IIT _d6~ Plan Ck. COIllllII nd
Charges ana 65%/Bldn PJ'r ~J;>e
Surcharges J. , '2,.. Plan Ck. Res
30%lBldo Per Fee
PLUI1BING PERMIT Fence
Charges and ------------
Surcharges Demo
ELECTRICAL PERI:IT Sidewalk
Cha rges and ------------
Surcharges A/C Pavi ng
11ECHAN I CAL PERMIT I Curb Cut
Charges and ------------ I
Surcharges
TOTAL VALUATION
Systems Development
Charce tI.5~)
Total Comb. Permit
I TOTAL
J
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~9 . 1:)./
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COMBINATION APPLICATION/PERMIT (CAP)
I. Appl icant to furnish
A. Job Address
B. Legal Description
1. example- Tax lot 100, lane County Map Reference
11 oj 43
2. examole- Lot 1. Block 3, 2nd Addition to
Springfield Estates
C. Name. etc. of owner and construction lender
O. Energy Sources
1. example- heat/electrical ceilinq/or forced air Qas
2. exa~le- waterheater/electrlcal/or SOlar
E. Square footage or valuation, etc.
1. example- 1250 sq. foot house, 500 sq. foot garage
2. 'example- if new project. check-new - if addition,
. cneck add, etc.
F. Building.'pennit information:
1. example - construct single family house with an
1 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. OESIGN 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.~ 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:
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PERMIT VALIDATION
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Permi t
cle~{[1L)
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
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date