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Permit Building 2010-3-4
~tural Permit Application _ . ::PRING..UtLD :;J ~~~ ". DEPARTMENT USE OrilL Y to....... z% -002-7'1 Permit no.: ~"-:_ """...::.1... ',' _"'~'7'Ji~~]"",;",~ \>~~l.'o. ~~~'t.~1::.dlt~1;s'"'t2~"i"".'''~;i!,~ ~:.rl , - . , ~ . .J;:ITY 'OF:S.~~INGFIELD~ OR~qQ.N~-.:i9.':'~ifg;:"*:'3t:;,:..~" 225 Fifth Streelt Springfield, OR 97477 t PH(54 1)726-3753 t FAX(541)726.3689 Date: '5 - -/0 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, , ".:' ',' ,"(O,'C'AL" :.'G'O'."V"E"'R'N'M'E"N",,.';'A,'6DR"O:"V"A,n>"IM:.,(,.::,""Ji<""" .,0 ;.;~~ .....\~ ..'. .. ._'___~_'_ _ .... ,', ,. ,"_/, .'f~ .._.' ,,_.,.~~';,,'?d}:::,-~;;':~,,''::''''~ This project has final land-use approval. Signature: This project has DEQ approval. Signature: Zoning approval verified: DYes Property is within flood plain: DYes. ..,,~. '.,-,.....'-,;;:"\".,..!lj..." '''''','' .. " '.'. ~",~..--,.."'.' .... '.,' r.iW~~,\<;~C;:ATE99~Y"J.OF',C.ON o Residential Gove ment 0 Commercial tNj~l:"i'89Ef~SliEi ff.lifoRMA T10N~ANq1.L.9PAfi9Nf~it:t\lj~;<i::; Job site address: +..h Date: Date: DNo DNo City: 77 Reference: Name: City: Phone: E.mail: ~::> ,. This installation is being made on residential or farm property owned by me or a member of my immediate family, and is exempt from licensing requirements und r ORS 01.010. Sig here: ..' ACTOR INSTAtLATIQN. . .~ s. , .' ". ' Bus me: Address: City: Phone: E-mail: CCB license no.: State: Fax: ZIP: Print name: Signature: l~{~t~~r;~!~?;~z:~su_~~t~~J[{Ac:rOF{UN~o~M~tIQN~~:~~+,~~fi~1~ Name CCB License Number Phone Number Electrical Plumbing Mechanical ':',', '; '. ~;':;S~.~;.-, :;"'i"-.~~(;'i,"~FEE 'S9H~pi.i[~f:'."':'\' :,},,:..,tf; ... ~. :., >"', ':i~Ya~.~fi~~).o'rf'ip_ f~~.IJ1~ti9~h.i:~~~iE~t'~\~~,t1~~;~,;~2:i~t~~:if.~~~_1;M~'[i,~J(~,~;t:~; (a) Job description: ~r\r,rv f.N.., I('(,,\.."'~l~ L. Occupancy Construction type: Square feet: Cost per square foot: Other infonnation: Type of Heat: Energy Path: o new ~alteration (b) Foundation-only permit? D addition DYes ,-EJ1'Io Total valuation: $ i:\ 9aoo 12:l~BUU~ing.: te~~':~2.~t;L,ifY~~4}fui~:;:7~t;;~~~~~z? ,.:i~!( "_'=/;}i1:~:~:,-,i::,:~,'j\'::;;:::-' (a) Permit fee (use valuation table): (b) Investigative fee (equal to [2a]): (c) Reinspeetion ($ per hour): (number of hours x fee per hour) (d) Enter 12% surcharge (.12 x [2a+2b+2e]): $ $ $ $ (e) Subtot.1 of fees above (2a through 2d): $ '. 3'7'iR....I"..~.>I1.~: ~~;f<:.-;t..i.'y~'" {./~.\'{:;;'.~~';,.~,i,"" ~'?1~,"~-',.,;.~'~~-p... ::'!1.~-',11',.,,~''<\'ittii'..'., - ,. ',- .,:, .' 3:~lr:ey_l~w:l~_e~s;.~i;;;v.~._~...../~~."'~,~;;;:lj::.;_~~~&;"~~*:r~I';,.:.?~~~ Jo\b (a) Plan review (65% x permit fee [2a]): $ ->'-' .> (b) Fire and life safety (40% x permit fee [2a]): $ (c) Subtot.1 of fees above (3a .nd 3b): $ B:~~~'M~~~~II~',~:~p:us1fe.~~t:~.<~:i~~t~;~~i~~i~~~:~~:~;',L.~ }~;-:'~L -~ <:' ''; . ,.'.,' ~. (a) Seismic fee, 1 % (.OJ x permit fee r2a]): $ TOTAL fees and surcharges (2e+3c+4a): S ;.. i.- o (j):> ,; -0 !'l ~ '5' ~ 'go ~~ 0-1:'" IJi"l c = g,<;'l, i'n tT.l en~ '&",i"l' '02" '0 "l' eir 00 I o ::T 0- m (") ::r r (1) :< 5: z ., ::; " ';;:; :1- " .,8 a -l " ~ ::1 " '" <- o ::T :J I '< ro :J 0-, o o :J '" . - ,.." C ("). -'. 6' :J ~ ;c: " ~ . 't:: S't::l ~' C?l trl < "Cl "!j w' g 0 o' g';%l ~ ,:j ~ , if> ;1<('"') o 0 t"':l gj ,g- ~ ,:=,:,g j ~ -,"" ,-""a,a' ::; e,>" ~;;;[.~ (; ".", '0 ~!4' 'g,o ',~, ,. 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Springfield Official Receipt Development Services Department Publie Works.Department RECEIPT #: 2201000000000000199 Date: 03/04/2010 2:31 :43PM Paid By LANE COUNTY SD 19 Item Total: Check Number Authorizati.on Received By Batch Number Number How Received djb 88005 In Person Payment Total: Amount Due 563.86 $563.86 , Job/Journal Number COM2010-00274 Description Plan Review CommlInd/Public Payments: Type of Payment Check Amount Paid $563.86 $563.86 cRcceintl Page 1 of 1 3/4/20 I 0