HomeMy WebLinkAboutPermit Building 1984-6-27
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Legal De'scriPtion\'1
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CITY OF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
I EnERGY SOURCES;
Heat
\./ater Heater
1 INSPECTION LINE
, 726-3769
Job Address c::9 J a
Ranqe
INFORllATION LlNE
726-3753 '
Sq. F tg. f.la i n
~q. !'"tg. Access.
Sq. Ftg. Other
Ne\~ Add Al ter Rep.
--Fence Demo Change/Use
--Other-- --
Ow,,, :6mN lr\ '<:-~QP Il.inl'J{
Address dl~ \~\ ~.' ,~ PhO~
, V':1JUf of I-Iork: cO
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Buildin~ Permit Info: Describe Work(i,e.,
Family Residence With Attached Garaqe)
Build Single
~
~
~
Address
DES I GN l1EAI.1
Cnamel
Phone
(address)
C'~n.C\.f\CW, f"\,(\~ ~
(' f)MN~r (OJA"'\l\..(.lnU- V-
- JJI.1'~CA.j)
(lies. no.) (exoires)
(ohone no.)
Construction Lender
Primary
Structura I
Electrical
Mechanical
CONTRACTORS (name)
~)
(address)
f.OOl
I
(exoires)
(ohone no.)
General
Plumbinq
(~ric.a-l' )
.~a";'-d~
PLUtlBItlG
ELECTRICAL
MECHANICAL
NO. '
, FEE' CHARGE NO,'
, FFF I rHARr,F NO.'
'FFF l rHARr,F
Each single fixture
Residence of
SQ. FT.
furnace/burner to
BTU's
/' .
Re loca.ted buil ding
(new fix. additional)
\
New circuits alts.
or extensions
,\(5 \O~
Floor furna'ce
and vent
IS.F. Residence'
(I bath)
IDup~ex (1 bath) each
IAdditional bath
1~la ter servi ce
Sewer
SERVICES
Recessed wall
Soace he~ter ~nd vent
',' Storm Sewer
I
I
I
I
:1
ITempOrary Construction
IChange in existing
residence
multifamily, comm, or
Industrial
Appliance vent I
seoarate
Stationarv evao..'f I
cooler. .
I Vent fan with I
, sinole duct
I Vent system apart from I
heating or A.C.
I Mechanical .'exhaust I
hood and duct
I }Iood stove/heater
I
I
I
I
Of amps.1
I COt~r,1. II NO. FEEDERS I I
IInstall/alter/relocate I I
distrib. feeders
10f amps.1 I
I I. I
I I I
1 I I ISSUANCE OF PFmlIT
TOTAL CHARGES \D.CD 1 TOTAL CHARGES
thatithe Electrical work be done by an Electrical Contractor, the electrical portionHof this permit
laberl has been signed by an Electrical Supervisor and .returned to the Building Division
I
I
,I
TOTAL CHARGES
, WHERE STATE Ul~REQUIRES
shall not be valid until the
Zone '2?
I HAVE CAREFULLY EXAMINED the icompleted application for permit, and do hereby certify that all information hereon is true
and correct, and I further certif~ that any and all work oerformed 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 OCCUPAIJCY will be made
of any structure without the permi;ssion of the [luilding Division. I further certify that my registration ~Iith the Builder's
Board is in full force and effect ,as required by ORS 701.055, that if exempt the basis for exemption is noted hereon, and that
ooly ,"btoot""o" "d "",ploy", .who '" '0 tom,it"" with oes 701.055 fibe ",~d2J/' ~". /1 .. .
lJAt.1E(please print)2/6.A4'C,O B/<'AA/c// SIGNATU~W~~~2!~/~~/~E&-U-8f?
FOr; OFFICE USCOflLY pr
So. Ftg. t1ain
Sq. Ftg. Access
Sq. Ftg. Other
Tyoe/Cons t. \. ~- \.. ')
Units \.
Occy Load
Occy Grou~- f2.-
x
Value
Value
Value
Fire Zone -
Bedrooms
x
Flood Plain ----
Stori es
x
TOTAL VALUATION \ ,(,"(")-
BUILDING PERf'lIT
Charges and
Surcharges
Plan Ck. Comm/Ind
65%/~lda Per Fpe
PI an Ck. Res -
30%/Bldq Per Fee
Fence
------ ----- ~I D@mo
____jO 00 I Sidewalk
. .. \..\D I A/C Paving
_____'WL~-Jcurb Cut
'I . I '
____~O:,~_-
. ,:\...\()
ISystems~ Development
Charqe (1.5%) "
I
I
I
I
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,
PLUNB ING PERMIT
Charges and
Surcharges
ELECTRICAL PERr~IT
Cha rges and
Surcharges
Total Comb. Permit
j
MECHANICAL PERMIT
Charges and
Surcharges
I TOTAL
() tb
LO.
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COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job Address
B. 'Legal Description
1. exam~le- Tax Lot 100, Lane County Map Reference
17 03 43
2. example- Lot 1. Block 3, 2nd Addition to
Springfielq ,Estat~s ,
C. Name; etc. 'of owner and construction lender
D. Energy Sources
1. example- heat/electrical ceilinq/o~ forced air qas
2. examole- waterheater/electricalior solar
E. Square footage or valuation, etc.
1. example~ 1250 sq. foot house, 500 sq. foot garage
2. example- if new project, check new - if addition,
check add, etc.
,F. Building permit information:
1. example - construct single family house with an
attached garage
2. example - remodel existing garage into family 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 Code
H. DESIGN TEAM AND CONTRACTORS
To avoid design or construction delays, Building
Division Staff must be able to contact appropriate
persons regarding design information or job site
corrections, etc.
II. Abbreviated Plumbing, Mechanical, & Electrical Schedules
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
have been abbreviated
2. If the item(s) to be installed are not covered on
the abbreviated schedules you should consult the
full schedules ,.
C. BUILDING DIVISION STAFF WILL FILL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
D. As noted on the CAP, the label must be delivered to ~he
electrical contractor. for signature by his electrical
supervisor. The general contractor is ,not authorized
to sign the electrical label. ---
III." Applicant to sign and date
Whenever possible, the initial application will be used as
a worksheet only. Where possible, Building Division Staff
will prepare a type written copy and return it to the
applicant at the time the actual permit is issued for his
signature.
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
fees are paid. All other fees and charges are due and
payable when the permit is issued.
V. FOR OFFICE USE ONLY
f
PROJECT CONDITIONS TO BE SATISF1ED BEFORE OCCUPANCY:
I
Permit Clerk
PERMIT VAll DATION
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. Ifl- 76- ~V
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Permit applicant exempt from registration with the Builder's Board because~
Additional Project Information:
PLANS REVIEWED BY:
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