HomeMy WebLinkAboutPermit Sidewalk 1984-3-5
I IrISPECTION LINE
726-3769
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Job Address I Q. -l1-- C/ h<.~
Legal Description \ tz.i:)t")
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INFORl1ATION LlNt
726-3753
Sq. Ftg. I.lain
~q. Ftg. Access.
Sq. Ftg. Other
New Add Alter Pep.
--Fence Demo Change/Use
Other - -
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CITY Of SPRINGfiELD
COMBIilATION APPLlCATION/PERMIT
E!/ERGY SOURCES:
Heat
Hater Heater
LtIv J
Ur\ t.fl ~
Ran!1e
ValuE of Hark:
lt~ ~
Address (j<9.,~n n~ D.
Ao.Zld
Constructio,( Lqtder
Owner
BullciinQ Permit Info: Describe Work(Le.,
Phone 79/.,,*, )'family ~esidence Hith A.ttached Garaoel
',I
Build Single
C;;;:idu.;',fW 6i.JtA1,G\j
<;( &,I~' 0 ~,;:f
(lies. no.) (exnires~ ' {ohone
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Address
Ut~IGN TEAl.!
(name)
Phone
(address )
Primary
Structura 1
Electrical
Mechanical
CONTRACTORS
(namel
(addrpss)
l1in.. no.)
(pxnirpc:)
(ohonfl nn,
Genera 1
Plumbino
Electrical
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IJL;. (Jy~( pJl.
PLUI!BI NG I) .
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37 () "Jd',f',J,-4w ~ 299'/<1;,0 9/z~:<;
MECHANICAL
Hechanical
ELECTRICAL
..J!ih I
Each single fixture
Fff rHARGF 'ill.... rr> rHAI!G.E. NO,
Res i dence of furnace/burner to
SQ. FT. BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
11 bath 1
IDuPlex (1 bath) each
IAdditional bath
I Ha ter servi ce
I Sewer
I Storm Sewer
I
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SERVICES
Recessed wall
So~~P hp~t~~ ~nrl v~nt
ITempOrary Construction
IChange in existing
rps.iqti::n(':~
I multifami ly, COfJJTI. or
Induc;tr;",l
I Of amps.
ICO~1./IND. FEEDERS
I Install/alter/relocate
rHc;trih fppr1prc;
IOf amp..1
I
I
I
Appliance vent
seoaratp
Stationary evap.
cooler
I Vent fan with
sinole duct
I Vent system apart from I
heatino or A.C. .
I Mechanical exhaust I
hnod and durt
j Hood stove/heater I
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TOTAL CHARGES
WHERE STATE LAH REQUIRES
shall not be valiJ until the
TOTAL CHARGES
that the Electrical work' be done by an.
label has been signed by an Electrical
ISSUANCE OF PFR!HT
TOTAL CHARGES
Electrical Contractor, the electrical portion of this permit
Supervisor and returned to the Building Division
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 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 rm OCCUPAfKY will be made
of any structure without the permission of the Building Division. I further certify that my registration with the Builder1s
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 comoliance with ORS 701.05f:'ill be~ ~~prOject.
UAI!E(please print) (?o 6 S'e-L""J .. SIGUATURE J Q,Q ':::;>~-- DATE 5c-'-\~ 'X'j"
FO~ OFFICE USE Q;lL Y 1- ,
Sq. Ftg. Hain x Value
Sq. Ftg. Access x Value
Sq, Ft9. Other x Value
Zone
Tvpe/Const.
Bedrooms
Stories
Units
Occy Load
Occy Group
Fi re Zone
Flood Plain
TOTAL VALUATION
BUILDING PWIlT
Charges an~
Surcharges
Plan Ck. Corrm/Ind
____________ ~/Bldo PPl" Fpp
Plan Ck, Res
30%/Bldo Per Fee
r Fence
I D~mo
I'Sidewalk
I A/C Paving
I Curb Cut
I
7)30
Systems Development
Cha rq. (1. 5~)
PLU'1BING PERMIT
Charges and
Surcha rges
ELECTRICAL PERI~IT
Charges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
'7. tV)
Total Comb. Permit
I TOTAL
I
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.
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
III.
I. Applicant to furnish
A, Job Address
B. legal Description
I. example- Tax Lot 100, Lane County Map Reference
11 U3 43
2. example- Lot I. Block 3, 2nd Addition to
Sprlngtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. examole- heat/electrical ceilinq/or forced air qas
2. examPle- waterheater/electrlcal/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. examole - construct single family house with an
attached garage
2. example - remodel existing garage into family room
3. examole - convert single family residence into
restaurant (chan-ge 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 fonm 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
O. 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. ---
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 penmit 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 penmit is issued.
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V. FOR OFFICE USE ONLY
Pennit Clerk
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because.:
Additi ona 1 Project Infonnation:
PLANS REVIEWED BY:
name
signature
date