HomeMy WebLinkAboutPermit Building 2009-7-15 (2)
Structural Permit Application
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225 Fifth Street. Springfield, OR 97477. PH(54 1)726-3753 . FAX(541)726-3689
\.DEP ARTMENT.USEONLY"
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Penn it no.:
Date: 7-/S -0 '1'
This permit is issued under OAR 918-460-0030. Permits expire if work is not started within 180 days of issuance or if work is
suspended for 180 days.
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This project has final land-use approval.
Signature: Date:
This project has DEQ approval..
Signature: Date:
Zoning approval verified: 0 Yes 0 No
Property is within flood plain: 0 Yes 0 No
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Residential 0 Government 0 Commercial
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Job sjte address: ~. , te
City:
Subdivision:
Reference:
Name:
Address:
City:
Phone:
-7
7 Fax:
E-mail:
This installation is being made on residential or farm property owned by
me Of a member afmy immediate family, and is exempt from licensing
requirements under ORS 701.010.
Sign here:
. 'CONTRACiT:OR.A~STrAtLATI9N~,
Business name: cJ...
Address:
City:
Phone:
E-mail:
ZIP: "17~1
Print name:
Signature:
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Name CeB License Number Phone Number
Electrical
Plumbing
Mechanical
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(a) Job description:
Occupancy
Constructi.on type:
Square feet:
Cost per squa.re foot:
Other information:
Type of Heat:
Energy Path:
o new D alteration
(b) Foundation-only permit?
Total valuation:
o addition
DYes
DNa
(a) Permit fee (use valuation table):
(b) Investigative fee (equal to [2a]):
(c) Reinspection ($ per hour):
(number of hours x fee per hour)
$
$
$
(d) Enter 12% surcharge (.12 x [2a+2b+2c]):' $
(e) Subtotal of fees above (2a through 2d): $
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(a) Plan review (65% x permit fee [2a]): $
(b) Fire and life safety (40% x permit fee [2a]): $
(c) Subtotal of fees ahove (3a and 3b): $
(a) Seismic fee, 1 % (.01 x permit fee f2a]):
$
TOTAL fees and surcharges (2e+3c+4a): $
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ATTENTION: Oregon law requires youto
follow rules adopted by the Oregon ~~~;ih
Notification Center. Those ru~e~:~ ~;2-001-
. OAR 952"001-001 0 throug
IOn090 You may obtain copies 01 the rules by
'. (Note: the telephone
calling the centoer. Utility Notification
number for the regon
Center is 1_800.332-2344).
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UAT HECEIVED '1'5'.0' .lO~ Nu.CO-~o -O/~.!3'
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'n.u: CONTENTS HERE ON HNlC: 8EEN RS',lIfZW'!f.Ci, '1,;"1"1:
):H..,.:,~n/..:-nONS INDICATED .oN COl..0;?t:\J :;'H~1'~.c':H... C.H...:'I1'.,,~.-<
~>;; /'.LTERATIONS MADE TO Tj-j'L /1, F'i-:'V.:O'.fH.D !"/i";'...W.\.ftl:....." (~~,.
P;~:::;'.;E.CT AFTER THE DATE f.jC'! c.W SHALL r~i;: ,:i.;':'r":.'~;'I''t.;'j :,t.
TH1:.', r~~l:LDING OFFICIAl...
CITY OF 5Pf1'iN(;t"I~l..i:J, om':G~.:M4
APPROVED BY P~~Jc. DATE 7;i~ 'i
NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK
AUTHORIZED UNDER THIS PERMIT IS NOT
COMMENCED OR IS ABANDONED FOR
ANY 180 DAY PERIOD.
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