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Home My WebLink AboutPermit Building 2004-6-4 .... CITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2004-00566 ISSUED: 06/04/2004 APPLIED: 05/12/2004 EXPIRES: 12/04/2004 VALUE: $ 35,000.00 '~. . '_ ~','i'Jl,.r'M!~!i!~~' , '~";'" ~, ' , ~. k i;: Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 1042 Water St ASSESSOR'S PARCEL NO.: 1703341102900 Springfield TYPE OF WORK: Manufactured Home on Private Lot TYPE OF USE: New Residential r-. REQUfRED PARKING ov.~"'\~ T~] ~-<:$ ~,o s,)" 2 1 ~~~~~l\;<:5 f-:J'Q~ Y es 'l..Qi~pact:. ~ :s.0 ~0 24 90 ~ III rol:? ~ <.; O. 0<::- . ~,'li }S' ~ 0.. ~0 if. v~ ~ 'Q" f-:J0 ~ 6" ,q} ~ I~J -~ l"'I r..:s _c, c> .l"'I V' ~! ^'" ,- ~y ~~ ,. ~" ~. oo~~. ~ -s' vo~ ~0-::.~ rJ ,~o _rofl!T,., '<;', ~Qi ~~..... ~<::- ~o ~~ a;rv w~~~l!!' ~ ~ 0<::- CJJ~ ' ~1t~~~IIt~~~~0~~urb and Gutter ,~.&,O <0)'<i5~ i$:-~ C; 0 ~ ~ ~4.0 ~ ~~~.. " ~ O~,~. .~~ ~,o ~ " ~ ~o; ~ ~t:li (JflJ (J :.:>~ ~ f,' ,- <,;.., PROJECT DESCRIPTION: M.H. on lot Owner: HARRISON PATRICK G & MYRNA B Address: 451 40TH ST SPRINGFIELD OR 97478 I CONTRACTOR INFORMATION I :~{" Contractor Type General Electrical ManufHome Inst Plumbing License 138060 63137 138060 138060 Contractor TRA VESS CONSTRUCTION RALPH W BROWN TRA VESS CONSTRUCTION TRA VESS CONSTRUCTION LLC ,I BUILDING INFORMATION I .~. # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: VN Electric Electric Electric # of Stories: Height of Structure Type of Heat: Water Type: Range Type: 3 Ener~~,~1f<6.: \!"..~m'e Riiilding: n/a -- n~ '\l" ,C; '0" ~ ~. _":11"~ ~\t,~.. ~\\~\..\. \00 "\ffH..~ INFORMATION I \\~ ~ ?t.\\~\\ \J~\Jt.\\ ~~~~\)\.l Frontyard Setback:\\\\\\Q~\tt.~~io\~Q\J' Overlay Dist: Side 1 Setback: ~~ ~~t.~C ~\ # Street Trees Rqd: Side 2 Setback: CO ,roru ~~, .00 Paved Drive Rqd: Rearyard Setback: ~~'{ 32.00 % of Lot Coverage: Solar Setbacks: 0.00 1 R-3 I PUBLIC IMPROVEMENTS I ., Street Improvements: Storm Sewer Available: Special Instruction: Fully Improved Yes SDC Credit for 12x20 garage. Notes: Paee 1 of3 Expiration Date 11/01/2006 02/15/2006 11/01/2006 11/01/2005 Phone 541-746-6399 541-729-1500 541-746-6399 541-746-6399 1 Lot Size: Sq Ft Ist Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: 1,620 . . CITY OF SPRINGFIELD Status Issued Building/Combination Permit PERMIT NO: COM2004-00566 ISSUED: 06/04/2004 APPLIED: 05/12/2004 EXPIRES: 12/04/2004 VALUE: $ 35,000.00 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line I Valuation Description' Description Tvpe of Construction $ Per Sq Ft or multiplier $1.00 $1.00 Square Footage or Bid Amount 5,000.00 30,000.00 Value Date Calculated Foundation On Iv Use Bid Amount Manuf Home Manufactured Home Total Value of Project $5,000.00 $30,000.00 $35,000.00 05/12/2004 05/12/2004 ~ Fee Description Amount Paid Date Paid Receipt Number Plan Review Residential $44.46 5/12/04 1200400000000000729 + 10% Administrative Fee $44.00 6/4/04 1200400000000000858 + 7% State Surcharge $30.80 6/4/04 1200400000000000858 Manuf Home State Issuance $30.00 6/4/04 1200400000000000858 Manufactured Home Connection $45.00 6/4/04 1200400000000000858 Manufactured Home Feeder $50.00 6/4/04 1200400000000000858 Manufactured Home Placement $160.00 6/4/04 1200400000000000858 Manufactured Home Service $50.00 6/4/04 1200400000000000858 Plan Review - Planning $71.00 6/4/04 1200400000000000858 Sanitary Sewer - 1st 50 Feet $45.00 6/4/04 1200400000000000858 Sanitary Sewer - Improvement $344.20 6/4/04 1200400000000000858 Sanitary Sewer - Reimbursement $452.80 6/4/04 1200400000000000858 SDC MWMC Administration $10.00 6/4/04 1200400000000000858 SDC MWMC Improvement $214.23 6/4/04 1200400000000000858 SDC MWMC Reimbursement $314.63 6/4/04 1200400000000000858 SDC Sanitary/Storm Admin $89.46 6/4/04 1200400000000000858 SDC Transpo Admin $54.86 6/4/04 1200400000000000858 SDC Transpo Improvement $727.42 6/4/04 1200400000000000858 SDC Transpo Reimbursement $164.89 6/4/04 1200400000000000858 Storm Drainage Impervious Area $658.30 6/4/04 1200400000000000858 Storm Sewer - 1st 50 Feet $45.00 6/4/04 1200400000000000858 Water Line -1st 50 Feet $45.00 6/4/04 1200400000000000858 Willamalane Manuf Home Private $1,000.00 6/4/04 1200400000000000858 Total Amount Paid $4,691.05 I Plan Reviews I Initial Review Planninl!: Review 05/18/2004 05/18/2004 05/18/2004 OS/21/2004 APP RJB APP TAJ Needs 32 sf of enclosed storage. Needs over the counter LDAP unless this is replacing a MH that was in the same location. Pal!:e 2 of3 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Public Works Review Structural Review . . CITY OF SPRINGFIELD. Building/Combination Permit PERMIT NO: COM2004-00566 ISSUED: 06/04/2004 APPLIED: 05/12/2004 EXPIRES: 12/04/2004 VALUE: ' $ 35,000.00 05/18/2004 OS/21/2004 APP VRJ Contacted owner and contractor regarding missing information on siteplan. Mike Travess came in and made changes to site plan. Researched demo permits on property, house demo #980229( to old for credit to apply) and garage demo Com2004-00104. SDC credit for garage impervious surface only, 12x20. Applicant to use existing curbcut and sidewalk. 05/18/2004 06/03/2004 APP RJB To Request an inspection call the 24 hour recording at 726-3769. All inspection requested before 7:00 a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following work day. L Reouired Insoections I 1 Manuf Home Set Up: When installation of all piers or stands is complete. 2 Final ManufHome Set Up: After all required inspections are requested and approved and porches, skirting, decks, venting, street address numbers, trees, driveway, etc. have been installed. 3 Sanitary Sewer Line: Prior to fIlling trench and including required testing. 4 Storm Sewer Line: Prior to filling trench. 5 Water Line: Prior to filling trench and including required testing. 6 ManufHome Plumbing: After home has been connected to water and sewer. 7 MH Electric: When blocking, setup and plumbing inspections have been approved and the home is connected to the panel. 8 MH Service: Approval required prior to utility company energizing service. By signature, I state and agree, that I have carefully examined the completed application 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 State of Oregon pertaining to the work described herein, and that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during const ctio. V""." Owner or Contrah~rs Signature l Date 6/ f)~/ c:2IJt1 i Pal!:e 3 of3 . ~... .ity of Springfield Official Receipt evelopment Services Department Public Works Department 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number COM2004-00566 ; COM2004-00566 " COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 ':. COM2004-00566 COM2004-00566 COM2004-00566 COM2004-00566 RECEIPT #: 1200400000000000858 Date: 06/04/2004 Description Manufactured Home Placement Manuf Home State Issuance Storm Drainage Impervious Area Sanitary Sewer - Reimbursement Sanitary Sewer - Improvement SDC Transpo Reimbursement SDC Transpo Improvement SDC MWMC Reimbursement SDC MWMC Improvement SDC MWMC Administration SDC Sanitary/Storm Admin SDC Transpo Admin Plan Review - Planning Willamalane ManufHome Private Sanitary Sewer - 1st 50 Feet Water Line - 1st 50 Feet Storm Sewer - 1st 50 Feet Manufactured Home Connection Manufactured Home Feeder Manufactured Home Service + 7% State Surcharge + 10% Administrative Fee Payments: Type of Payment Paid By Check PATRICK HARRISON Item Total: Check Number Authorization Received By Batch Number Number How Received djb 1101 In Person Payment Total: 6/4/2004 Page I of 1 3:01:17PM Amount Due 160.00 30.00 658.30 452.80 344.20 164.89 727.42 314.63 214.23 10.00 89.46 54.86 71.00 1,000.00 45.00 45.00 45.00 45.00 50.00 50.00 30.80 44.00 $4,646.59 Amount Paid $4,646.59 $4,646.59 . SP.FIELD DEVELOPMENT SERVICES DEPARTMENT 225 FIFTH STREET SPRINGFIELD, OR 97477 (541) 726-3753 FAX (541) 726-3689 MANUFACTURED HOME LAND USE AGREEMENT As required by the City of Springfield Development Code, 1 agree that with the approval of the attached pennits, one of the following manufactured homes will be placed at J 04 z- Wit- T€:{L ~ Springfield, Oregon, City Job NumberC61'11 ZC;oy -a05bb y. Type I Manufactured Home. A multi-sectional (double wide or wider) unit with an enclosed floorarea of not less than 1,000 square feet, that has a nominal roof pitch of 3 feet in height for each 12 feet in width, that has no bare metal siding or roofing, and that has been certified by the manufacturer to have an exterior thennal envelope meeting perfonnance standards which reduce heat loss to levels equivalent to the perfonnance standards required of single family dwellings constructed under the State , Specialty Codes. Type II Manufactured Home. A unit of not less than 12 feet in width with an enclosed floor area of not less than 500 square feet, that has a nominal roof pitch of2 feet in height for each 12 feet in width and that has no bare metal siding or roofmg. The manufactured home shall be placed on an excavated and back-filled foundation not to exceed 6 percent slope within 10 feet of the perimeter enclosure. The perimeter foundation wall surrounding the home shall be constmcted of stone, brick or other masonry materials, and with no more than 24 inches of the enclosing material exposed above grade. I further agree to meet all land use and City Code requirements of the above mentioned parcel within 60 days of the date of Issuance of the manufactured home set up pennit. These requirements may include, but are not limited to the items listed below. Specific land use requirements regarding your parcel are noted on your approved set up plans and/or pennit and your partition approval if applicable: . Street Trees . Paving Driveway . Minimum 32 square foot storage structure . Completion of partition approval . Removal of any existing structures as noted on your partition approval . Signing and recording of any required partition, easement, improvement agreements, etc. o Final lot grading . City Sidewalk and curbcut installation . Any outside agency approval as required i.e., Division of State Land approval. below, I agree to complete the above mentioned land use requirements. ~/I1'1/zHJf Dattl I Contractor Signature Date . ., .' . . .p..~WiUama[ane t~ . Park & ReCr:::::~S::ELOPMENT CHA~:: No. CDM RCA)~~5Co ~ . WORKSHEET , NAME: ~~~~C\\~~\~~~ . PHONE: It.t\-'C\O D AOo'RESS: '--\C)t . J-.U)\h ~~, S~\~~ STATE: QJSt ZIP:, q1L{1& tOCA TIQN OF PROPOSED BUILDING SITE: Street Address:- ',}~p~ _~": U~ ~~\iro. ~\'- Plat Name:' \ 1. ~ ~J-\ \\, '<" Tax Lot Number: ~(t'\D 1~ 'OEVELOPMENTTYPE (Checl<appropriate dwelling(s). sac calculations and dwelling t ype definitions are on the back.) , ' . ' A. SlnqlA-Familv Qetached Single Family home NO. OF UNITS \ 'l. Manufactured home not in a park ' ,X $1.000 per unit = $ l CJDO <JO,' ,- B. i?in0N:.F~rrtily Attached NO. OF UNITS X $924 per unit ,=. $ C. Multr..Familv Aoartment NO. OF UNITS X .$692 per unit = $ l?.fv1amlf;:;lctI1reci Home Parli NO. OF UNITS , WILLAMALANE SOC X $699 per unit = $ $' \OOO.DD ,r;j 2. SDC CREDIT (If applicable) SDG-payer must furnish proof of Willamalane 'credit approval. See sac Credit Worksheet. $ 3. TOTAL WILLAMALANE NET SDC ASSESSED {If SDC reduced {or Credit) $ 0'0 /6C5D-- .~~~ . e pment Se~ces Department City of Springfield h / L( / O'L( Date " 225 FIFTH STREET SPRINGFIELD, OR 97477 (541 )726-3753 FAX (541) 726-3689 www.ci.springfield.or.us MANUFACTURED HOME SET-UP AGREEMENT \r#' As required by the City of Springfield Development Code, I understand and agree that wi~e approval of . the attached permits, one of the following manufactured homes will be placed at loZ'~ WtLL.,; s+ , Springfield, Oregon, City Job Number . ~ ~ .. ~~~~ (. Type I Manufactured Home: A multi sectional (double wide or wider) unit with an enclosed floor area of not less than 1,000 square feet, that has a nominal roof pitch of 3 feet in height for each 12 feet in width, that has no bare metal siding or roofmg, and that has been certified by the manufacturer to have an exterior thermal envelope meeting performance standards which reduce heat loss to levels equivalent;R/:J. t performance standards required for single family dwellings at the time of construction. ---r . initials A unit 0 ot less than 12 feet in width enclosing a minimum floor area of 500 square feet, that has a nominal ro pitch of 2 feet in height for each 12 feet in width, that has no bare metal siding or roofing, and that has en certified by the manufacturer to have an exterior e al envelope meeting performance standards whicH educe heat loss to levels equivalent to the peru e standards required for single family dwellings a: the time of construction. initials /I I further state, by my signature below, that I have been provided with the following information: Manufactured Home Blocking, Water Line Connection, Street Tree Standards, Sanitary Sewer Connection, . Electrical Connection, and Minimum requirements for permanent steps. I also understand that the manufactured home shall be placed on an excavated and backfilled foundation not to exceed 6 percent slope within 10 feet of the perimeter enclosure, enclosed at the perimeter with stone, brick or other concrete or masonry materials approved by the Building Official and with no more than 24 inches of the enclosing material exposed above grade. . fill- --- b/otJ/2~f Date I { SignatuYe r l' . CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT WORKSHEET JOURNAL OR JOB NUMBER: Com2004-00566 NAME OR COMPANY: Patrick Harrison LOCATION: 1024 Water Street TAX LOT NUMBER: 17033411 tI 2900 DEVELOPMENT TYPE: SINGLE F AMIL Y RESIDENCE NEW DWELLING UNITS 1 BUILDING SIZE (SF' 1620 LOT SIZE (SF): I. STORM DRAINAGE DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S.F. x I COST PER S.F. CHARGE I I 2270.00 I $0.290 I = I $658.30 RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS I IMPERVIOUS S.F. x I COST PER S.F. x I DISCOUNT RATE I I DISCOUNT I 0.00 I $0.290 I 50% I = I $0.00 ITEM 1 TOTAL - STORM DRAINAGE SDC I $658.30 I 6534 C/l ~ Cl o U ~ ~ r-< C/l ...... o ~ $658.30 1070 2. SANITARY SEWER - CITY A. REIMBURSEMENT COST: I NUMBER OF DFU's I x I COST PER DFU I 20 I I $22.64 $452.80 1091 B. IMPROVEMENT COST: NUMBER OF DFU's x I COST PER DFU 20 I $17.21 $344.20 1092 ITEM 2 TOTAL - CITY SAN IT ARY SEWER SDC = I $797.00 :i 3. TRANSPORTATION A. REIMBURSEMENT COST: I ADT TRIP RATE x NUMBER OF UNITS x I COST PER TRIP x INEWTRIP FACTOR I I 9.57 1 I $17.23 I 1.00 I $164.89 1093 B. IMPROVEMENT COST: I ADT TRIP RATE x NUMBER OF UNITS x I COST PER TRIP x INEWTRIP FACTOR I 9.57 1 I $76.01 I 1.00 =' , $727.42 11094 ITEM 3 TOTAL - TRANSPORTATION SDC = I $892.31 4. SANITARY SEWER - MWMC A. REIMBURSEMENT COST: NUMBER OF FEU's x ICOST PER FEU 1 I $314.63 = $314.63 I 1054 B. IMPROVEMENT COST: INUMBER OF FEU's I x COST PER FEU I 1 I $214.23 = $214.23 1055 MWMC CREDIT IF APPLICABLE (SEE REVERSE) $0.00 1054 MWMC ADMINISTRATIVE FEE $10.00 11056 ITEM 4 TOTAL - MWMC SAN IT ARY SEWER SD< = , $538.86 ._- SUBTOTAL (ADD ITEMS 1, 2, 3, & 4) = I $2,886.47 5. ADMINISTRATIVE FEE: I SUBTOTAL I x I ADM. FEE RATE CHARGE I $2,886.4 7 , I 5% $144.32 TOTAL SANITARY ADMINISTRATION FEE: 89.46 11079 TOTAL TRANSPORTATION ADMINISTRATION FEE: $54.86 11078 I Virginia Jurasevich 5/21/2004 TOTAL SDC CHARGES =1 $3,030.79 PREPARED BY DATE . DRAINAGE FIXTURE UNIT (DFU) CALCULATION TABLE NUMBER OF NEW FIXTURES x UNIT EQUIVALENT = DRAINAGE FIXTURE UNITS (NOTE: FOR REMODELS, CALCULATE ONLY THE NET ADDITIONAL FIXTURES) NO. OF FIXTURES DRAINAGE UNIT FIXTURE FIXTURE' TYPE NEW OLD EQUIVALENT UNITS BATHTUB 2 0 3 = 6 DRINKING FOUNTAIN 0 0 1 = 0 FLOOR DRAIN 0 0 3 = 0 INTERCEPTORS FOR GREASE / OIL / SOLIDS / ETC. 0 0 3 = 0 INTERCEPTORS FOR SAND / AUTO WASH / ETC. 0 0 6 0 LAUNDRY TUB 0 0 2 = 0 CLOTHESW ASHER / MOP SINK 1 0 3 3 CLOTHESW ASHER - 3 OR MORE (EA) 0 0 6 = 0 MOBILE HOME PARK TRAP (I PER TRAILER) 0 0 12 = 0 RECEPTOR FOR REFRIG / WATER STATION / ETC. 0 0 1 0 I RECEPTOR FOR COM. SINK / DISHWASHER / ETC. 0 0 3 = 0 I SHOWER, SINGLE STALL 0 0 2 = 0 ISHOWER, GANG (NUMBER OF HEADS) 0 0 2 = 0 ISINK: COMMERCIAL/RESIDENTIAL KITCHEN 1 0 3 = 3 I SINK: COMMERCIAL BAR 0 0 2 = 0 ISINK: WASH BASIN/DOUBLE LAVATORY 0 0 "- 2 = 0 I SINK: SINGLE LA V A TORY /RESIDENTIAL BAR 2 0 1 = 2' URINAL, STALL / WALL 0 0 5 0 TOILET, PUBLIC INSTALLATION 0 0 6 = 0 TOILET, PRIVATE INST ALLA TION 2 0 3 = 6 MISCELLANEOUS DFU TYPE NUMBER OF EDUS , . 20 0 TOTAL DRAINAGE FIXTURE UNITS 20 *EDU (Equivalent Dwelling Unit) is a discharge equivalent to a single family dwelling unit (20 DFU's) set at 167 gallons per day MWMC CREDIT cALCULATION TABLE: BASED ON COUNTY ASSESSED VALUE YEAR ANNEXED BEFORE 1979 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 CREDIT RA TE/$I ,000 ASSESSED VALUE $5.04 $5.04 $4.95 $4.88 $4.75 $4.58 $4.41 $4.20 . $3.88 n50 $3.07 $2.60 $2.14 $1.71 $1.52 $1.38 $1.19 $1.03 $0.87 $0.68 $0.46 $0.27 $0.09 $0.04 IS LAND ELGIBLE FOR ANNEXATION CREDIT? (Enter 1 for Yes, 2 for No) IS IMPROVEMENT ELGIBLE FOR ANNEX. CREDIT? (Enter 1 for Yes, 2 for No) BASE YEAR o o 1979 CREDIT FOR LAND (IF APPLICABLE) VALUE / 1000 CREDIT RATE $0.00 x $5.04 '- I . - $0.00 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) VALUE / 1000 CREDIT RATE $0.00 x $5.04 = , o TOTAL MWMC CREDIT $0.00 ~t 225 FIFTH STREET. SPRINGFIELD, OR 97477 · PH:(541)726-3753 · FAX: (541)726-3689 ELECTRICAL PERllfIT APPLICATION City Job Number ((\;;/ZCT'(I'-(:(~ ~l;(.. Date 200 Amps or less 201 Amps to 400 Amps 40 I Amps to 600 Amps 601 Amps to 1000 A~8\O overlOOOA_~~~\~\~ Reco~s:lt~e~O(\ ~ \O~ .. -" ~ ~e9P'(\ ~e e $ :\.. 9 Cf-S.- ,?,~\\\O~~~~~k' t>--' ,I,..-' ~'J.\eS f\\e~' ~'(~<? 0\ "K\0(\0 ,o\\<~~ \\0(\ C~\~~~at~~~ri~~~ation ~o\\\'v~ ~~~.(j ~illrlP~:~!fP" ~\\'J ~o~: $ 50.00 $\ O~ iO'J. ({\ ~~~~ ~ $ 69.00 ()~~\\(\~ \~~~~~li\~~ Amps $100.00 ~.;.,)~'Oe1 ~~.~~oAmRs.o~ 1000 Volts see "B" above. D. Branch Circuits New Alteration or Extension Per Panel One Circuit , Each Additional Circuit or with /-l'H.~\,;~-\- ',..( j Service or Feeder Permit ~ $ 3.00 t / (. .J L '~~ 'j E.~Iisd~llan~()tl;~~~~1o.. ..... Ijl.lclU......d.......ed)lE.~ch.Installation _. '. ./ ~\'f\'t;\\- ~\\\'O. Phone . lLt (. <~>( -~(':t:. pu~~~f~~ ?~~t.~ ~\J\\ $ 50,00 .' , \\ \:." V\.\\\~~ ~~ $ 50.00 OWNER INSTALLATION \\\\~\\$\\\~~~\li~~~8~esidenti~1 $ 2~.00 The in.stallation is being made on property I own ~hiCIf~\)\~\\!~~~~~~rgY/COmmercIal $ 4).00 IS not mtended for sale, lease or rent. ~\~-n~um Electric Permit Inspection Fee is $45.00 + Surcharges 4. \DO.r:JJ 1. ibc,A;IIONOfINSTALUTlbN j{iLf Z~ C!.A-T{~~vL ' .~-- LEGAL DESCRlPTION . -") ,'. ) ) L_I' \ \ I / C' .::,) JOB DESCRIPTION~ tft.1 I I ;Illi (>'r"/, ;/,k., ., . .. -. Ct." JC '-- '), JL, I ~ .~.".t \i,~ ;- 1 c - L~. +- Permits are non-transferable and expire if work is not started within 180 days of issuance or if work is Suspended for 180 days. 2. Electrical Contractor ~t, J -;1. - ltCLC~ ;(I-r'~ .~ ", Address /{-, '-I u City c;~ Phone 71 f-I ~C;1<-' Supervisor License Number Expiration Date /{}/I/t.)q Constr. Contr. Number ~ 3/3 7 ;J () ,- i.f $" I ~~ /~ / I //.It./ I - Expiration Date Signature of Supervising Electrician ke/il/- t J . /rJAYi- . I__~, ( Owners Name 1)4- .~..~ ILL lc . Address 1.1 ',;; I City .,.... - j' - --"f ' ...J: - Owners Signature: Inspection Request: 726-3769 ~^rJ W ~~~~\j 3. COll1:l'Ll:.-'~J1iFEiSClIEDULE BELOW '::,::', A. New Residential"': Single or Multi-Family per dwelling ul~it. Service Included 1000 sq. ft. or less Each additional 500 sq. ft. or portion thereof Each Manufact'd Home or Modular Dwelling Service or Feeder $106.00 $ 19.00 ~ $50.00 \004r:x) B. $ 63.00 $ 75.00 $125.00 $163.00 $375.00 $ 50.00 $ 43.00 7% State Surcharge 10% Administrative Fee .~ { I; " ( l_- TOTAL / /7 c; [ - Shared DIive(T:)/Building Fanus/Electrical Pennit Application 1-03.doc . Construction Contractors Board. 700 Summer St NE Suite 300 PO Box 14140 , Salem OR 97309-5052 Phone: 503-378-4621. . Web Address: www.ccb.state.or.us . . . . Pennit #: COWl' 0" - CO .;;-Eo, b Address: 104 L W;4-:TEL S\"' Issued by: ~ ~ Date: b,L:ijo 4 'Statement: ,Information ~otice to Property Owners About Construction Responsibilities . Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. This statement is required for residential building, electrical, mechanical and. plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS701.010(7), need not submit this statement. This statement will be filed with the permit. Fill in the appropriate blanks arid initial boxes 1 and 2', and eitherbox3A or 3B: . ~ 1. ~.'2. I own, reside in, or will reside in the completed strUcture. I understand that I must become licensed as ~ construction contractor l.fthe structure is sold or -- . offered for sale before or on completion. . ' A 3A.My general contractor is', ., ~ V ~ ~ eoV'\... ~*-~c.......h 0 \-. (Name) 1'5.'2'0(;0 (CCB #) . I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR D- 3B. I will be my own general contractor. If I hire subcontractors, I will hire only subcontrac,tors licensed with the Construction Contractors Board. If! changemY,mind and hire a general ,contractor, I will cOlitract with a contractor who is "',J licensed with the,CCB and will immediately notify the office issuing this building permit-ofthe name ofthe contractor. I hereby certify that the ab9/' ove info mation is correct and that I have read and do understand the Information Notice to Property Owners onstruction Responsibilities on the reverse side of this fOlm. '/' ~~__- .' ~/(j'f !,Lt)ai (SignatuM' of permit applicant) I (:q)ate) . (White copy to ,issuing qgency permitjile; pink copy to' applicant.) Property...,.owner.doc 03/11/03 . . , ! Acting as Y our Own General Contractor? INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RE'SPONSIBllITIES . . NOTE: This Information Notice to Property Owners about Construction Responsibilities was developed by the Construction O;mtractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature. If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and concerns. Employer Responsibilities You wi11, in.most instances; be ruled to be an "employer" and the contractors you contract with wi11 be "employees" if . you usecontraGtors not licensed with the Construction Contractors Board to do labor in constructing or to assist in the construction or improvement of a residential structure. As the employer, you must comply with the following: Oregon's Withholding Tax Law: As an employer, you must 'Withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For a State Business ill number, call the Business Information Center at 503-986-2200. Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488. Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and'must obtain workers' compe,nsation insurance for. your employees. If/you fail to obtain workers' compensation insurance, you could be subject to penalties and.be liable for all claim costs if one of your employees is injured on the job. For more information, call the Workers' Compensation Division at the Department of Consumer and Business Services at 503-947-7815. '".,' ; . U.S. Internal Revenue Service: As an employer, you must withhold federalhicome tax from employees' wages. You wi11 be liable for the tax payment even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 866-816-2065 or fax them at 801-620-7115. , Other Re~ponsibiliti.es and Areas of Concerns Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements that may be brought to your attention through inspections. Liability and Property Damage Insurance: Contact your insurance agent to see if you have adequate insurance . coverage for accidents and omissions such as falling tools, paint over spray, water damage .from pipe punctures, fire or . work that must be red.one. Time: Make's.fue you ha~e-~~ffitient time to supervise'your employees. , , ': . ~ ~ J: I.~ .~~ , . Expertise: Make sure you have the skills to act as y~ur own general contractor, to coordinate the work of rough-in , and finish'trades; and to noiifybuilding officials as the appropriate times so they can perform the required inspections. If you have additional questions call the Construction Contractors Board (503-378-4621) or write the agency at PO Box 14140, Salem, OR 97309-5052. Property _ owner.doc 03/11/03