HomeMy WebLinkAboutPermit Building 1981-8-12 (2)
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INSPECTION LINE
72~J769
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INFORMATION LINE
726.3753
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CITY Of SPRINGFielD
COMBINATION APPLlCATION/PUMIT
Job Addren
" D~ \ <"\; O~l An ~ (\)
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Sq. ftg. Main
Sq. FIg- Accon.
Sq. fIg. Other
_New _Add _Alter _Rep.
_n _feMe _Demo_Change j U se
_Olher
Legal Description
I ~:::GY S~?X
Waler Heater
Ronqe -
Value of Work:
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Own" [$t 1..1J)l'L- '- J.. )&:t~~y
Add''''~~~~~ r \('),a,~~\.l)_Q,) IS ~~~7;~gR:,~~:~t,~n;;'th ~::~:~:d::':~~;' 'uad Singl.
Conwu";on l.~d.~ . I).... ') I (\C-yp ) t I-J\.dJ:J. J '('\\ \?\..
Address Phone
Mechonicol
CONTRACTORS (name) (address)
I G.n.,al ~(\ I\oJLd. \1\...(\, (JO '- ~M.o t\ J
I P1umb;"a LnLL.""l'(\,\J---
I BecHicol ~ Jr--...c_>-
DESIGN TEAM
(nome)
Primary
Structural
Electrical
Mechanical
PLUMBINC
NO. I
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! Eoeh sinqle f;;Jtlvre
'I' R~locorlld building
(new fix. additional)
I S.f. Residen!=l!
11 both)
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Ouolell; 11 balh) eacn
Additional ba,h
Waler service
Sewer
I Slor.m Sewer
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TOTAL CHARGES
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(oddreul
(lies. ~o.)
(u;pirei)
(phone no.)
(l;cs. nc.)
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! CHARGF I
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(expire$)
(phone no.)
ELECTRICAL
MECHANICAL
.---~~--rFEE
furnace/ burner to
lITU's
Applionce'vent
separate
Stationar:,' ovop.
cooler
Vent fon with
sinqie duct
Vent .sY$tem oport from
heatinq or A.C.
Mechanical exhaust
hood ond duct
f::J:
CHARGE NO.
FEE CHARGE I NO.
Residence of
SQ:ft.
New circuits. alteratiolls
or extensions
SERVICES
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Temporary Construction
Amps.
Wood stove/heater
FEEOERS
Heot Puma
Air handler to
10.000 CFM
Air handler o....r
10,000 CFM
Amp$.
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ISSUANCE OF PERMIT .
TOTAL CHARGES
TOTAL CHARGES
WHERE STATE LAW REQUIRES Ihat the Electrical work be done by the Ele.-tricol ContraCTor, the electrical portion of this permit shall not be valid until a
label ha~ be.n signed by on Electrical Contrortar and a"oched to th. electrical panel.
I HAVE CA.,REFUlLY EXAMINED the completed applkation for permit, and do her.by certHy thai 011 information hereon is true and (orrect, and I further
certify that any and 011 work. performed sholl be done in accordance with the Ordinances of the City of Springfield and the lows of the State- of Oregan
.pertaining to the work described herin, and that NO OCCUPANCY will be mode of any structure without the permission of the Building Division. I further
certify that my registration with the Builder's Beard is in full force and effect as required by ORS 701.055, that if exempt tho basis for exemption is noted
heron, and that only svbcontroctors and employees who are in camplionce with ORS 701.0~S will be uad on this project.
Basis for Builder'~ Boord e:JI.emption'
NAME (pleose print) Lo....lA.J("Q...
Zon-
Fire Zone
Flood Plain
BUILDING PERMIT
Charges and
Surcharges
PLUMBING PERMIT
Charges and
Surcnarges
ELECTRICAL PERMIT
Charges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
vJ;\4-'::l.€..Y
c:.IGNA TUR~1\...A..J..Jt.J
FOR OffiCE USE ONLY
.
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om ~-I;;;l.-t (
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Typel Canst.
"'-drooms K.-J J
"tori.'
<:.~. FIg. Main
Sq. Ftg. Accen
Sq. Ftg. Other
Value
Val\,le
Value
TOTAL VALUATION
Units
""cy Load
Occy Group
x
x
2J5?='
Pia" Ck. Commllnd
65':01 Bldo Per Fe"
Plan Ck. Res
30%1 Bldq Per Fee
Systems De...elopment
Charae 11.5~..\
\ ~_ cD
LoO
\D,CO
,40
---..QJL .
J/l
fence
Demo
Tolol Comb. Permit
Sidewalk
.14 1<: Pavina
Curb Cut
19.\ w
TOTAL
APPLlCA TI9N/&IT
COMBINATION
I. Applica~ to furnish
(CAP)
A. Job Add re55
B, Legal Description
1. example-tax Jot 100, Lane County Map Reference 17 03 43
2. example-Lot 1. Block 3, 2nd Addition to Springfield Estates
C. Nome. etc. of owner and construction Jender
D.. Energy Sources
1. example-heat/electrical ceiling/or forced o;r gas
2. exomole-water heater/electrical/?, solar
E. Square1fo,otoge or valuation, etc. ,'I , I
1. examole-1250 sq. foot house. 500 sq. foat garage
2. example.jf new project, check rJe;,-if addition, check
add, etc.
F. Building permit information:
1. examo/e-construct single family house with an attached
garage
2. example-remodel existing gorag~ into faniily room
3. example-convert single family residence into
restaurant (change of use)
G. Value of work as defined in Section 303 (a) of the
Structural Specialty Cade
H. DESIGN TEAM AND CONTRACTORS
To ovoid design or construction delays, Building Division
Stoff must be able to contact appropriate persons regarding
design inf~rmation or job site corrections, et~.
II. ,Abbreviated P:lumbing, 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. To conserve space on the permit form the schedules
hove been abbreviated
2. If the item(s) to be installed ere not covered on the obbrevi.
ated schedules you should consult the full schedules
'C. BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES,
III. Applicant to sign end dote
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 signatur&.
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 fe7~ 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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Additionol ,Project Infarmation:
PLANS REVIEWED BY:
name
signaturf"
.
Permit Cler~
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PERMIT VALIDATION
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INSPECTION LINE
72t..316f
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INFOIl:MATlON LINE
716-37.53
CITY OF SPRINGFIELD
COMBINAJlCN APPLlCAflON/PEIlMIT
Job "'ddr~u
'. D~ \ <}(". O~l ~<~ r0
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I ~:::GY S~?X S
Waler Healer
Ronqe _
Value of Work:
i Sq. Fig. Main
I Sq. fig. Ac't8n.
Sq. Fig. O,h.r
I _Ne.... _Add _Alrer _Rep.
_.. _Fencl! _Oemo_Chongei U lit
_Oth.r
Legol Description
Own" [ r. 1\ \"\Cl..__ '- J.. J &t ~Q.... Y
I Add,." \r;y;; \ f\ ~ f'i ~ \(' ~j,a{..)
I S~N. ~T'J(~ ~\_' f\\l\('-QS Ie:.,
I COIHlruction lende~
I Addren
~ DESIGN TEAM
Structural
I Electrical'
.1 Mechanical
I CONT~ACTORS (Mme) (oddress)
I G.ne,ai ~(\ I\oJLd. \1\...(\, (J 0 '- ~M.o r:" J
I Plumbina, ~'"1<\. \J---
I electricol~)t'...o>-
(nome;
Primary
Mechanical
PLUMBINe
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8uilding Permit Info: DetCribe Work (i.e., Build Single
Fomil... Re,idOl!l'''~e With Attached Goreu:!!!!l
Phone
{\l (\('Vp ) t \...J\n.<.LJ '('\\~
(oddren)
(lies. no.)
(u;pirln)
(phone no.)
(lies. no.)
(expires)
bhano na,l
ELECTRICAL
, I
CHARGE I
NO.
fEE
CHARGr:,
MECHANICAL
FEE
NO. I
F::1O
CHARGE I NO.
WHERE SlATE lAW REQUIRES thai the EI.drical work be done by the Ele.-tricol ContracTor. the electrical portion of Ihi. permit shall not b. yalid until a
10b.1 ho,. been signed by an Electrical Contractor and attached to tho elec:tricoJ pan.l.
I HAVE CA,REFUllY EXAMINED th. completed application for permit, and do hereby certify Ihot all information hereon ;s trlJe and correct, and I f""rther
certify that any and all work performed ,hall be done in accordance with the Ordinanus of the City of Springfield and the law) of the State of Oregon
pertaining to the work descrio..G h.rin, and Ihat NO OCCUPANCY will b. mad. of any s"""ctur. without the perminian of the Building Division. 1 furth.r
atrtify that my registration with the Builder's Board is in full force and effect as required by ORS 701.055, thai if oxempl the. basis for exemption is noted.
horan, and that only subcontractors and employees who are in compliance with ORS 701.0.5.5 will b. usad on this project.
Basis for Build.r's Board .xemption:
NAME (please print) Lo...u....ra...
i
i Eocn ,inl:lle fill.lvre
'I' R~locared bvilding
{new ti.ll. additionail
I S.F. i1:<!liden~e
(1 bath)
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OuolelC 11 bod,} eoc;,
Additional balh
Water ,enice
Sewer
I Stor.m Sewer
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, \ iN\1\
I
TOTAL CHARGES
Residence of
furnace/ bvrner !o
. ~TU's
Appliance yent
separate
Stationarj' iIIvap.
cooler
Vent fan with
singie duct
Vent system aport from
heati~q or A.e.
Mechanical exhausl
hood Clnd d~ct
l,
Sq: ft,
New circuits, aheralialls
or elCtensiQns
SERVICES
Temporary Construction
Amps.
Wood sta..../h.ater
FEEDERS
Heat PumD
Air handler la
10.000 CFM
Air handler onr
10.000 CFM
Amps.
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I TOTAL CHARGES
\DCD
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ISSUANCE OF PERMIT
I TOTAL CHARGES
<IGNA TURcJJf"LVJ'tJr1...
fOR OffiCE USE ONLY
.
\J;\~~e...y
lJ)~
Q<
OATE ~-I;;l,-tl.
Zone
Fire Zone
Flood Plain
Type/ Canst.
~drooms r-:.J J
<::tariel
BUILDING PERMIT
Charges and
Surcharg.s
~5~
-
PLUMBING PERMIT
Charg.s and
Surcnargos
\~.co
loD
\D.CO
,40
elECTRICAL PERMIT
Chorgos and
Surchargos
MECHANICAL PERMIT
Charges and
Surchargos
Units
()ccy load
("lccy Group
Sq. ftg. Main
"q. Ftg. Accon
"q. Ftg. Other
Value
Value
Value
TOTAL VALUATION
.
.
plan ek. Camm/lnd
65~~/ Blda Per Fen
Plan Ck. Res
JO%J 8ldq Per Fee
Systems O....elapment
ChorQl! (1.5~)
FenCl!
LJDL.
J/J
Demo
Total Comb. Permit
Sidewalk
Alc Payino
Curb Cvt
~\ w
TOTAL
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. APPLICATION/_Mil (CAP)
COMBINATION
I. Applica~ to furnish
A. Jab Address
B. legal Description
1. eXam ole-tax lot 100, lane County Map Referer
2. example-lot 1. Block 3. 2nd Addition to Springf
C. Name, etc. of owner and construction lender
D.. Energy Sources
1. example-heat/electrical ceiling/or forced oir go
2. exomole-water heater/electrical/or solar
E. Square footoge or valuation, etc. -
1. example- ~ sq. foot house. 500 sq. foot gara!
2. example-if new project, check new.if addition. c
add. etc.
F. Building permit information:
1. example-construct single family house with an a
gorage
2. exomole-remodel existing geragE:: into family rOI
3. exam pie-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,DESIGN TEAM AND CONTRACTORS
To ovoid design or construction delays, Building Div
Staff must be able to contact appropriate persons fe
design inf~rmation or job site corrections. etc.
II. Abbreviated Plumbing, Mechanical & Electrical Schedul,
A: 'Except where.blank spaces occur in the description ~
of th.e Mechanical and Electrical Schedules, the appli
need fill.in only the No. Boxes adjacent to the appro
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 schedul
have been abbreviated
2. If the item(s} to be installed ore not covered on th
aled schedules you should consult the lull schedul
'C. BUilDING DIVISION STAFF Will Fill OUT All FEES A
CHARGES ON THE SCHEDULES
III. Applicant to sign and date
Whenever possible, the initial application will be used 0:
worksheet only. Where possible, Building Division Staff,
prepare 0 typewritten copy and return it to the applieanl
the time the actual permit is issued for his 5ignatur~.
IV.
(
I-
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 ore due and payable when the permit
is issued.
V. FOR OFFICE US,E ONLY
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY,
Additional. Project Information:
PLANS REVIEWED BY:
name
signatur....
~ I
.
"
\
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PERMIT VALIDATION
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CITY OF SPRI NGFIELD
City Hall
Springfield, Oregon
Department of Public Work.
'OFFICIAl RECEIPT
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No. B S 7 0 6 2
Date (\m C'\ \ k 199<) \
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AUTHO"IU:O SIGNATURE
...'[LTO...Tl,J"......LL ~"'''T,[''S. '[uQE'n. 0" 17.0'
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Amount
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