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Home My WebLink AboutPermit Building 2011-1-3 .J . . s~~~r~.~:~;ii) .w.:">~ -:,'. ,;~ OREGON CITY OF SPRINGFIELD Building I Residential Permit PERMIT NO: 811-SPR2010-00748 IVR Number: 811137849671 www.ci.springfield.or.us 225 Fifth SI Springfield,OR 97477 Phone: 541-726-3753 Inspection Phone: 541-726-3769 Fax: 541-726-3676 permilcenter@ci,springfield.or.us PROJECT STATUS: STATUS DATE: ISSUED: APPLIED: 01/03/2011 11/19/2010 Issued 01/03/2011 EXPIRES: VALUE: 07/02/2011 $31,000.00 SITE ADDRESS: 2763 21ST ST, Springfield, OR 97477-1767 ASSESOR'S PARCEL NO: 1703244202728 SCOPE: Single Family Residence WORK INVOLVED: Addition TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: Family room addition Phone Number: OWNER: ADDRESS: DELLER MICHAEL JAMES & K 2763 N 21 ST ST SPRINGFIELD OR 97477 CONTRACTOR INFORMATION ~ Contractor Type Contractor Name MIKE GANSEN CONSTRUCTION COMPANY Lie Type GGB # of Units: o BUILDING rNFDRMATION ~ # of Stories: Height of Structure: Type of Heat: Wall Heat Water Type: Range Type: Hazrnat: # of Bedrooms: Sprinkled Building: No Fire Alarms: No Energy Path: Electrical Specialty Code Edition: Springfield Fire Code Edition: Mechankal Specialty Code Edition: Municipal I Development Code: Plumbing Specialty Code Edition: Residential Specialty Code Edition: Structural Specialty Code Edition: Lic No 92159 Lic Exp 06/14/2011 Phone 541-463-1000 Lot Size: Sq Ft 1st Floor: 252 Sq Ft2nd Floor: Sq Ft Basement: Sq Ft Garage: Sq Ft Carport: Sq Ft Dther: 144 Occupancy Load: 2008 Site Information ~ Engineered Fill: No Fill Volume: Flood Hazard Area: Yes Land Hazard Area: . N,;>" _ 8-008- f S! Ja\UaQ Retaining Wall: (rNO'~ c8 u06aJO a4\ JOl JaqwnU - ""''''''01\1\(1'' J\\lp\n 6 SOils Report Required: d" No "'a\ON) 'Ja\UaO a4\ U!lIBO au04 ala\ a4\ ' , '0600 Aq SalnJ a4\ 10 sa!doo U!B\qo J\BW no;,. UI ~Wg;fis6 a~:~a~Jnao~~~f f'~d~;~~g~~;~B~~~~~ hl!l\n u06aJO a4\ Aq pal OpB o'\'noA saJ!nbaJ MBI u06aJO .NOIIN3111,1 ~ ' .;'. ';.;')' '..... NOTICE' . ..., . THIS PERMIT SHAll EXPIRE IF THE WORK. AUTHORIZED UNDER THIS PERMIT IS NOT COMMENCED OR IS ABANDONED FOR -,. ANY 180 DAY PERIOD. " Springfield Building Permit 1/3f2011 12:13:14PM Page 1 of 4 . . CITY OF SPRINGFIELD 225 Fifth St Springfield,OR 97477 Phone: 541-726-3753 Inspection Phone: 541-726-3769 Fax: 541-726-3676 www.cj.springfield.or.us Building I Residential Permit PERMIT NO: 811-SPR2010-00748 IVR Number: 811137849671 permitcenler@cLspringfield,OLUS " PROJECT STATUS: STATUS DATE: Issued 01/03/2011 ISSUED: APPLIED: 01/03/2011 11/19/2010 EXPIRES: VALUE: 07/02/2011 $31,000.00 SITE ADDRESS: 2763 21ST ST, Springfield, OR 97477-1767 ASSESOR'S PARCEL NO: 1703244202728 SCOPE: Single Family Residence WORK INVOLVED: Addition TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: Family room addition DEVELOPMENT INFORMATION ~ Frontyard Setback: Interior Setback: 28.5 Sideyard Setback: 32 Rearyard Setback: 33.5 Solar Setback: 1.5 Overlay Dist: # Street Trees Reqd: Paved Drive Reqd: % of Lot Coverage: Highest point on structure to north property line: Flood Plain REQUIRED PARKING Yes Total: Handicapped: Compact: 14 PUBLIC IMPROVEMENTS ~ Street Improvements: Storm Sewer: Storm Sewer Available: Speciallnstructon: Subdivision Accepted: Notes: Application received 12/29/2010. Stormwater connect to existing eaves. Partially Improved Curb and Gutter No Sidewalk Type: Downspout/Drains: Valuation Description I Description Bid Type of Construction NA 'Unit Amount Unit Type 31,000.00 Bid Unit Cost 1.00 Value 31,000.00 31,000.00 FEES PAID ~ Descriotion Amount Paid Structural Plan Review Fee Residential $212.01 ~~min fee (10% 2L~pplicable fees) __. _..___ $1.98 SDC: Total Sewer Administration Fee $11.52 -.-.,. " ~~.2r':90n Surcharge (12% of applicable fees) $39.14 T.':c~n~logy fee (5% of permit tot.~Il__ ___.___ ____ $16.31 ~DC: lmprovem_:.~~_~~~_~~rm Dr!:.~age_~__________ ___..~,~148.5~__,. SDC: Reimbursement Cost - Storm Drainage $81.81 Resid.ential Fire (.05 Per Sq Foot) $19.80 Structural Buildin9 Permit Fee $326.17 Total Amount Paid $857.30 Date Paid Reciot # 11/19/2010 2010000872 01/03/2011 2011000004 01/03/2011 2011000004 01/03/2011 2011000004 -------- 01/03/2011 2011000004 - --- --- -- --- >.. 01/03/2011 2011000004 . -.--- - - 01/03/2011 2011000004 __"'-n_._._._ _"...,...___.___ 01/03/2011 2011000004 ~.._,- -"~.,- --.,.- - 01/03/2011 2011000004 Springfield Building Permit 1/3/2011 12:13:14PM Page 2 of 4 . ,.' CITY OF SPRINGFIELD Building I Residential Permit 225 Fifth Sf Springfield, OR 97477 Phone: 541-726-3753 Inspection Phone: 541-726-3769 Fax: 541-726-3676 www.cLspringfield.or.us PERMIT NO: 811-SPR2010-00748 IVR Number: 811137849671 permitcenter@ci.springfield.or.us PROJECT STATUS: STATUS DATE: Issued 01/03/2011 ISSUED: APPLIED: 01/03/2011 11/19/2010 EXPIRES: VALUE: 07/02/2011 $31,000.00 SITE ADDRESS: 2763 21ST ST, Springfield, OR 97477-1767 ASSESOR'S PARCEL NO: 1703244202728 SCOPE: Single Family Residence WORK INVOLVED: Addition TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: Family room addition Plan Review ~ Deoartment Received Due Date Completed Result Reviewer Planning Review 11/23/2010 11/23/2010 11/23/2010 Waiting internal Deyette Kelly Comments: Approval of building permit is subject to approval of Floodplain Overlay Application TYP110-00013 which was received. on 11/23/2010. S'tructiIr~I~'Review::,>,s,;,:, !>''d,;,f:; ;;:'1/23/201 0:'",~11123720lb:i:' f1/23/201 0-,:,"" '.Ad<j'f;lnfO ~eq.uired~-' , ,_' ""'>t';:' ~. '~~~',;:, ,-~" -:':': "',,:,'2.- .-:-"" _-,:: ;~-:':. C' ~ ,- " .'kho74-\t,,<c ,". ~ ';.. ..t: ._"'~; }'""f:,. -;-r,~~""'';~''- <Co~rryW~~,~~:~ ~e'e~'initialflooct-eleva,tioncertificat~,: -.-.:,;~ ~ . ....". .. ::~~) ::., !~i.iif':';~,;.~, . ~. Application Acceptance 11/19/2010 11/19/2010 11/23/2010 Appllcation Accepted Chrii(a'a;:p~~"~T0~'~~~-"-. , . 'I ;. ",5ir:':!~t,"~"P",;~~, ..., ., '. .1 ~ "~" .i'';'- <"~'';:";...._..::~,~_,___~...:~J Chris Carpenter Planning Review 11/23/2010 11/23/2010 12/28/2010 Comments: According 10 Floodplain Overlay Review TYP11 0-00013: Approved Deyette Kelly Provide a second FEMA Elevation Certificate completed by ,a certified engineer, surveyor or architect. performed while the building is under construction to be provided to the Building Inspector at the time of the post and beam inspection and a third after construction of the addition, but before occupancy. The finished floor elevation of the new construcllon shall be a minimum of 12 inches above the base flood elevation. Anchor as necessary to meet Building Codes. Construction materials and methods shalt be designed to prevent flood damage. Utilities shalt be designed and located to prevent ,,__",,___~ _'..- wat~W=~!:.ntering:~he ~Rptic~':l~ke~p alt r~cord_s.!9-~ in~peS!~~_~ !Public Works Review " ,1J123/2010,. 11/23/2010 " 12/30/2010.. Approved.~;:." i ,T~d~S!~~I~ton ;f'~: L:f~~~_eM~!s; :APp;j~atiq~Tec~iVed]: 2;?~~i5~ ~t~~;~te;,,29~Q~c,(tbk'~~iSti~9 e'a~e~:{~:~. :~~~'::i:::A ,,~t~:'::', ~ % Structural Review 11/23/2010 11/23/2010 01/03/2011 Approved Chris Carpenter Comments: As noted on plans, attachments. and FEMA attachments , "-"'.,\ ~.Jt!:JS2L?-'~J Springfield Building Permit 1/3/2011 12:13:14PM Page 3 of 4 S~~!NG~.FIE~D.~ ~'~s..i~ n.., ""~ '. ...,,'" " OREGON CITY OF SPRINGFIELD 225 Fifth St Springfield,OR 97477 Phone: 541-726-3753 Inspection Phone: 541-726-3769 Fax: 541-726-3676 wviW.ci.springfield.or.us Building I Residential Permit PERMIT NO: 811.SPR2010.00748 IVR Number: 811137849671 permitcenter@ci.springfield.or.us PROJECT STATUS: STATUS DATE: Issued 01/03/2011 ISSUED: APPLIED: 01/03/2011 11/19/2010 EXPIRES: VALUE: 07/02/2011 $31,000.00 SITE ADDRESS: 2763 21ST ST, Springfield, OR 97477-1767 ASSESOR'S PARCEL NO: 1703244202728 SCOPE: Single Family Residence WORK INVOLVED: Addition TYPE OF STRUCTURE: Residential PROJECT DESCRIPTION: Family room addition INSPECTIONS REQUIRED I Inspections 1992 Final Construction.Elevation Certificate 1110 Footing 1120 Foundation Footing: After trenches are excavated. Foundation: After forms are erected but prior to concrete placement. Post and Beam: Prior to floor insulation or decking. Framing Inspection: Prior to cover and after all rough in inspections have been approved. 1170 Post & Beam 1260 Framing 1410 Underfloor insulation 1420 Insulation Vapor Barrier 1430 Insulation Wall Wall Insulation: Prior to cover. 1440 Insulation Ceiling 1530 Exterior Shearwall Ceiling Insulation: Prior to cover. Final Building: After all required inspections have been requested and approved and the building is complete. 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 or 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 re uested at the proper time, that each address is readable from the street, that the permit card is located at the front e ope ,and the approved set of plans will remain on the site at all times during construction. 1999 Final Building ~?-// , Owner or Contractor Signature Date Springfield Building Permit 1/3/2011 12:13:14PM Page 4 of 4 "J U:S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE Federal Emergency Management Agency , National Flood Insurance Program Important: Read the instructions on pages 1-9. -. OMS No. 1660-0008 Expires March 31,2012 ' SECTION A - PROPERTY INFORMATION 'Foi""nsuran6e.Company'Use:._ . ..... .j' Al. Building Owner's Name Mike and Alisa DeUer ,Policy__Nu~ber:~ - . .. '...., '. 1\2. Building Street Address (including Apt, Untt, Su~e, andlor Bldg. No.) or P.O. Route and Box No. Company.NAIC Number' I, 2763 N 21" Street , I. .. , . .......,::..,>.d. " City Springfield State OR ZIP Code 97478. A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) Lot 15, 2nd Add~ion to EI Bon~a Gardens Map 17-03-24.42 Lot #2728 A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) Residental AS. Latjiude/Longltude: La!. 44.07539 Long. 122.99341 Horizontal Datum: 0 NAD 1927 [8] NAD 1983 M. Attach at least 2 photographs of tile building if tile Certificate is being used to obtain flood insurance. A7. Building Diagram Number l! AS. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) 1110 sq ft a) Square,footage of attached garage ill sQ ft b) No. of permanent flood openings in the crawlspace or c' b) No. of permanent flood openings in the attached garage enclosure(s) w~hin 1.0 foot above adjacent grade 2 within 1.0 foot above adjacent grade Q c) Total net area of flood opanings in A8.b 691 sq in c) Total net areaof flood openings in A9.b Q d) Engineered fiood openings? . 0 Yes [8] No d) Engineered flood openings? 0 Yes SECTION B. FLOOD INSURANCE RATE MAP (FIRM) INFORMATION sqin [8] No I B1. NFIP Community Name & Community Number B2. County Name I B3. State I Lane County, UnicofJlorated Areas - 415591 Lane OR ] B4. Map/Panel Number B5.Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9 Base Flood Elevation(s) (Zone I 41039C-1153 F Date Effective/Revised Date Zone(s) AO, use base flood depth) I June 2, 1999 June 2, 1999 AE 452.44 Bl0. Indicate the source of the Base Flood Elevation (8FE) data or base floo,d depth entered In Item 89. . 0 FIS Profile 0 FIRM [8] Community DetelTOlned 0 Other (Describe) _ Bl1. Indicate elevation datum used for BFE in Item B9: [8] NGVD1929 0 NAVD1988 0 Other(Describe)_ 812. Is the building located in a Coastal Barrier Resources System (CBRS) area or otherwise Protected Area (OPA)? 0 Yes Designation Date _ 0 CBRS DOPA [8] No SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: [81 Construction Drawings* 0 Building Under Construction* 0 Fini$hed Construction * A new Elevation Certificate will be required when construction of the building is complete. I C2. Elevations - Zones Al-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARiA, ARiAE, ARIA1-A30, ARiAH, ARiAO. Complete Items C2.a.h below according to the building diagram speoified in Item A7. Use the same datum as tile BFE. Benchmark utilized See Comment Vertical Datum 1929 Conversion/Comments City of SDrinafield Bench at 2933 Yolanda Dublished bench - 459.60' f) g) h) Top of the next higher floor Bottom of the lowest horizontal structural member (V Zones only) Attached garage (top of siab) Lowest elevation of machinery or equipment servicing the building (Describe type of equipment and Jocation in Comments) Lowest adjacent (finished) grade next to building (LAG) Highest adjaoent (fmished) grade next to building (HAG) Lowest adjacent grade at lowest elevation of deck or stairs, including structural support 451.~ n/a._ 450.1 450.1 450.z ~.l! ~.I Check the measurement used. [8] feet 0 meters (Puerto Rlc~ only) 121 feet 0 meters (Puerto Rico only) o feet 0 meters (Puerto Rico only) [8] feet 0 meters (Puerto Rico only) [8] feet 0 meters (Puerto Rico only) 0) b) c) . d) e) Top of bottom floor (Including basement, crawfspace, or enclosure floor) 449.1 [8] feet 0 meters (Puerto Rico oniy) [8] feet 0 meters (Puerto Rico only) [8] feet 0 meters (Puerto Rico only) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTlFICA TfON This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the information on this Cerliticate represents my best efforts to interpret the data available.! understand that any false statement may be puniShable by"ne or imprisonment under 18 US. Code, Secbon 1001.[8] Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a licensed lend surveyor? [8] Yes 0 No ~ Io+."~__ Certifier's Name David Wellman License Number OR PLS 2163 Company Name D. Wellman Surveying PROFESSIONA LANDSURVEYO w U OREGON JULY 1985 DAVlO H. WELL 2163 Title President Address 90686 Northrop Drive City Eugene State OR ZIP Code 97402 Date 12/1012010 Telephone 541-984-1442 RENEWAL: b/~j,2.. - er=a.^ e__ 04~,f .._.. ''\I'' C"..._ .......___ _:,..l_ &_. __.....:_.._,;__ n__I__...... ..II _.._..:....... _..1:...:...__ SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) bUilding owner. Comments A5 - Determined with GPS on site. B9 - Elevation received by Springfield Planning. C2 (a) - Addition crawlspace level indicated on plan.s is same as measured at residence at same elevation. C2 (b) - Existing residence living floor elevation. Addition floor level as indicated on plans dated 10f27f201 0 to be 1.58' higher at elevation 453.5 feet. e2 (e) - Hot water heater, furnace, and laundry on garage slab. ~ Signature --..., ,.., j / J IV Dete 12/1212010 ..-/~ ,ff.t-/ei1/--- [gj Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) IMPORTANT: In these spaces, copy the corresponding infonnation from Section A. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. 2763 N 21'1 Street . < City SpringfieldState OR ZIP Code 97478 For Zones AO and A (willlout BFE), complete Items El-E5. If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A, B, and C. For Items E1-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters. E1. Provide elevation information for the fOllowing and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (inclUding basement, Cfawlspace, orenelosure) is _._ 0 feet 0 meters 0 above or 0 below the HAG. b) Top of bottom floor (including basement, crawlspace, or enciosure) is _._ 0 feet 0 meters 0 above or 0 below the LAG. E2. For Building Diagrams 6-9 willi permanent flood openings provided in Section A Items 8 and/or 9 (see pages 8-9 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is _._ 0 feet 0 meters 0 above or 0 below the HAG. E3. Attached garage (top of slab) is _._. 0 feet 0 meters 0 above or 0 below the HAG. E4. Top of platform of machinery andlor equipment servicing the building is _'_ 0 feet 0 meters 0 above or 0 below the HAG. E5. Zone AO only: If no flood depth number is available,' is the top of the bottom floor elevated in accordance with the communfty's floodplain management ordinanoe? 0 Yes 0 No 0 Unknown. The local olliciai must certify this information In Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A. (without a FEMA~iBsued or community-issued BFE) or Zone AO must sign here. The statements in Sections A, a, and E are correct to the best of my knowledge. Property Owner's or Owner's Authorized Representative's Name Address CitY State ZIP Code Signature Date Telephone Comments o Check here if attachments G2.o G3.o SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, e, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8 and G9. G1. 0 The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) A community official completed Section E for a building located in Zone A (without a FEMA-issued or communjty~issued BFE) or Zone AO. The following information (Items G4~G9) is provided for community floodplain management purposes. G4. Permk Number G5. Date Pennit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permk has been issued for: 0 New Construction 0 Substan1iallmprovement G6. Elevation of as-bulk lowest fioor (including besement) of the bUilding: _._ 0 feet 0 meters (PR) Datum _ G9. BFE or (in Zone AO) depth of flooding at the building site: _ _ 0 feet 0 meters CPR) Datum _ Gl0.Communily'sdesignfioodelevation __ ofeet o meters (PR)Detum _ ,. Local Official's Name Title Community Name Telephone Signature Dale Comments re.." 1:"...... 0.01 0).01 .'.....,..t'\ o Check here if attachments n__l__...... ...11 _.......:........ _",,:.:___ !. For Insurance Company Use: . Building Street Address (including Apt., Unn, Sune, and/or Bldg. No.) or P.O. Route and Box No. Policy Number 2763 N 21" Street i City Springfield State OR ZIP Code 97478 Company NAlC Number I I If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to the instructions for Item A6. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View' and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page, following. Building Photographs See Instructions for Item A6. Front View-1211012010 . ....1 .... ......~~ ... .;~~~S:~~,~J~;M:r;i;ji:;~4~lt~~~i~~ Rear View-12/10/2010 __ """7" A . '.. '" <t <t '" '" o ... 1..aBl~'" WS o O. . ... is A . \ :II ~......_--..~...---.... I"L~'aa ~'-"1l3 'm! l 390llla' N30AlIH J.33'I.LS """... 0l>S eN .~ .e;...._ ~--:iII~~....~....---'-'O;:-'-.- - .. ,.. Ii rilE ~ .~ '~ 0" - ... . o. .. .1. a: l t ,. ~ il '1-' 'U) g . o 2 I ~ ~ s . -~- ~ Ii 1-- -:r.r- o . ~~ . - --- ~--A-._' i g ; . . ,. .; . t 0 I' . .. .Z \l!l. ~ .J: , OJ 5 ~ s.'" ~ ;a! ~ '" a: U) >- ... j:; ... Z <t s: .0 '" U E d .~ .. '" '" z !; .. ...J ... '" ~ ~ z , , 00.(- - . ~ % ~ ,. r~~'-;;;>:!"-,:; v ~g J~ +Jl! i ~..If ~~ ~i/~~ if . " " *M . " . . . - . - ':r' .", . "~-S- ~ I 8 ... ~ ~ ti_ i -- ~~ . " . N {" , $ ~ ~ " I ~ ~ . - !I~>P-- .t ~ 1.1 dOI\l us - o I en 5 ~ . ~+ .2___. - t. ~ U) . ... z ~ ~I = 1'1<: . 8 i ... ~ -- . .% . . <S-. .;,' .,. 225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 City Job Number 510-0L/~ Date II/;E!jo . o I & 2 Family Dwelling or Accessory 0 New Constructi6n I 0 o Multi-Family ;0.. AdditionlAlteratiou/Replacement 0 o . Commercial/Industrial _0 Tenant Improvement Job Address 27 to ~ IV Z{ ~ / ~ Bldg No. Lot /? Block 'l-"O /1-00 Subdivision H I?omfA. r;.Avt/of5Tax Map/Tax Lot Project Name Description of Work/location on premises/special conditions O ~(Ht1\"'*U!f~..:",4:;~."''''.l1!l1!'?;Eitl1!l1!'*~l1!l1!'fP;iIl!;~~l1!l1!':(. ~C1t~:i}~lQJte17",'S!i;:~4l*<i"","i'0^4~~"""i'&rti\rt~">' .....~, Name M\J-~€- \ fl\-\\SJl- Pell tp'{' Mailing Address 2. 7(" 'S N Z / s,- 51. City b'J'rt "1 ~(-e {o State oe... Zip 'nfl ~ Phone(5"YO 7'1'0-'13(,1- . . Fax Owner Representative Phone Fax o Name MailingAddress 3"2... r-lvJY 1'1,.1 CitY EUU4-1 -e... State O!L. Zip 7'7 7U z- Phone(SSlV 5'.f>'?-/OOO Fax If#) r63-/0D! ..11,.1P':'::'/ T,W" . ';," ,,','"!'i ,"';1:,,'" :E, "",;c&"'itif:' Yf!fJ:$~ . . di.~~~, o iitf1rchitecJ/JYe$ig:n<d'ZJf,,1aiu.~eJi:(??JriiiIl;l1!l1!'iIl!f?,. Name-/i~fO(;;;i;;;C,#s.~Y) . . Address /(0 0 3/I-C 0/3 ~ City ;;;U~ State ~/L.. Zip r;r /oz- . Contact Person j!.. cAC ;41 c..;tI-<2 ""eI'i- .. / ~ Phone (}'ft) YG/-2PYL-. Fax Demolition Other Suite No. /7-05 -2....9' -~""i7d New Dwelling Area Garage/Carport Area Other Structure Area SQFt 'Jf'2- - x $/SQ Ft Value l'f'l Existing Building Area New Building Area TotaJ\TaJue Existing New Occupancy Group( s) Const. Type(s) Number of Stories e. II ?, [ Phone # (5"W?6! /000 D iJ[~~tQ!;(~~l;~4fr~ ',;%, ~','jh ~ Contractor's Namy General r-7/I7V Se/ UJ k S I Plumbing Mechanical Electrical O "f,~..u'"AP.,w..4'IiYT""~ .'.wP "'I'~~ 0 ~""._.. ..........Z.,.,. .'" '.. ....P_~,~~,filC~.,""~_"~Uk_~W1"""-'. ,. b:tt;:()!!1J!!~J;Cttt /:iJ.nu:u.stnlU,'.L~;,I;Q)~ j;;;!.~~s,:ZHe.nhg." t~inQJ~.t$~;Af~;:~flfili,rpi!F;r/j~l-fjwrptiITf]lL,':!bk%L~iI~ji?$fl;!!%+;4"';L~:"'i1,0! Has site review application been submitted? Heat Source: Primary iN 1'\'1...'-- f\.eZ. \ Secondary o Yes 0 No 0 N/A Water Heater Range Energy Path If so, Name of Planner Do you require any of the following for this project? Journal Number Over-width or Second Driveway 0 Yes 0 No Temporary Power 0 Yes 0 No Notice: All contractors & subcontractors are required to be licensed with the Construction Contractors Board of the State of Oregon under rovisions ofORS 701 and ma be re uired to be licensed in the jurisdiction where work is bein erfonned. CCB# 7''Z-()'/ Expiration Date 20/2.- BUILDING DATE PERMIT APPLICATION Shared Drive(f:)/Building FonnslBuilding Pennit Application lO-02.doc .. www.ci.springfield.OLUS TRANSACTION RECEIPT 811-SPR2010-00748 2763 21ST ST CITY OF SPRINGFIELD 225 Fifth St Springfield, OR 97477 541c726-3753 permitcenter@ci.springfield.or.us RECEIPT NO: 2011000004 RECORD NO: 811-SPR2010-00748 DATE: 01/03/2011 [[IESCRII'TIOjij' ,,-':5,',;' iT ,'''',''''P'i\:,'': i)t -" ~"Zj;_1?,J,,;z:;~~;;;:~:g_cJ$,ullf:::CL()):i.E'<_,;;>i,,_i: ;~M!'!.l!t-lJ' Dl!!"', -"" '1 Residential Fire (,05 Per Sq Foot) 100-00000-424005 $19.80 SDC: Reimbursement Cost - Storm Drainage 441-00000-448029 $81,81 Structural Building Permit Fee 224-00000-425602 $328,17 SDS.!r:r'.~emen~ost -~ Drainag~___ 440-00000-448028 J>~,56_ Admin lee (10% of aeplicable ~esL___ ----, , 224-00000-426605 ____ ~__, ._,_!1~~ SDC: Total Sewer Administration Fee 719-00000-426604 $11.52 ._-~-_'-"-_--~--,-.....----,. . - --- State of Oregon SlJ'charge (12%,01 aee~"able leesL______________8,2..1:0'OOOO-2_15004 _ __ _ _ _~~?;~ Technology fee (5% of permit total) 100-00000-425605 $16,31 TOTAL DUE: $645.29 ~; I'AVMENfrVHEh; :"PAYOR;':i.;CASHIER' DB6w'@11~:(.;,:jG.()MM~NtSE;\'~~T;;:Tfi~;_;~;,"/:;~'\:-'AMOUNT PAID "-' '.: .1 Credit Card 07726c michael gansen $645.29 $645.29 S.!.RIN.......G.~L.D Ir~ ..,...; ~ ,,'1~ OREGON www.ci.springfield.or.us TRANSACTION RECEIPT 811-SPR2010-00748 2763 21ST ST CITY OF SPRINGFIELD 225 Fifth 5t Springfield,OR 97477 541.726.3753 permilcenter@cLspringfield.or.us RECEIPT NO, 2010000872 RECORD NO, 81 I-SPR2010-00748 DATE,11/19/2010 I DESl::RIRTI0N'''' 'co':,:,.c, _." ---,~ : -;-~- ~.: ~ : .~7.:: ,_~-;_ ~ - ~i::_C.o.U.N'rLC::QDE "... :-, -i :~MOJJNTDUE' .' - H; I Structural Plan Review Fee Residential 224-00000-425602 $212.01 TOTAL DUE: $212.01 ~ . PA VMENT TVI"E~:~d; I"A VOR:.~: :CASt"E,,' CCARPEN.1ER"; COMMENTS;: ~;"'.~:'P-+ - ::: ":' ; :AMOUNT PAiD T: -;: Check 8181 MIKE GANSEN CONSTRUCTION COMPANY $212.01 $212.01 \, \ ~