HomeMy WebLinkAboutPermit Building 1981-9-28 (2)
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1 HISPECTION LINE CITY UF SPRINGFIELD INFURlIATIDN LlNt
726.3769 CDrIBHIATlON APPLICATION/PERMIT 726-3753
L!{,! k:J (-'f- EIIERGY SOURCES: Sq. Ftg. I.Iain
Job Address "/.,.';,.<_ VI';"'r)" , r <t A
..., \,.,. v L.......... Heat _q. . g. ccess.
L 1 D "./ ,,!-later Heater Sq. Ftg. Other
ega e,crlpt.on 1lLk'1...., LDr '/:'. EHJbi!JfJJ.D n615.
'0.4-_ "7 - - Ran". e ~lew_Add_A1ter ......:qep.
:1 ________ Fence Demo Change/Use
17-03..3<1-/4 '1/...35'0" ValUE of Hork: ,,, Other--
OwnerR<""~S";f> YY1.l4v Du VI V"" (,9QO-
./ r"1 Builciino Pennit Info: Oeser,be Work{;.,e.. Build Single
AddreSS~_b--! R tv -.0...... U i~ I ...j ~~;--_ PhO~~~~?~ Familv Residence Hi th Attached GaraQe)
1?AN\ove d....d f?~f\aep rA<t'ft....-t
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Construction Lender
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Address
DES I GrI TEAl.'
(name)
Phone
(address)
(lics.no.1
(exnires)
(nhane no.'
Primary
Structural
A.WJlI-f"
~~'( r<,....rP(!
Electrical
Mechanical
CUNTRACTORS
Plumbina
(name)
IdrqJ ~u."<I'f'((
...( )/I'7t r i:'
;tJ i) 1l,)~
(address) (lies. no.)
rlM.<;+. c.. 8?6f!vCff.13tFiaf'J {. / sC)
(exoir~s)
(ohone no.)
Genera 1
r-J?:;J...
12;(6-/J~.
Electrical
~lechani~aL..& ~)\.J I.::;
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PLUllBIrlG .
ELECTRICAL
MECHANICAL
NO,
FEE CHARGE 'lP
I:lL ~..1lQ.....
~~ I' .!JiARlif
Each single fixture
Residence of
SQ. FT,
furnace/burner to
BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
11 bath I
Duplex (1 bath) each
Additional bath
SERVICES
Reccs~ed wall
~n~rp pp~tpr ~nrl vpnt
Storm Sewer
Of
amps.
App 1 i ance vent
s~oaratE>
Stationary evap.
cnol""r
V"ent fan with
sinole duct .
Vent system apart from
heatina or A.C.
Mechanical exhaust
hood and dud
Sewer
Temporary Construction
Change in existing
rp'i j d.p.n~p
multifamily. comm. or
Industrial
Water service
COMfl./INO. FEEOERS
Install/alter/relocate
rlic:.trih_ fpprlprc:.
Wood stove/heater
Of
amps.
ISSUANCE OF PFRr1IT
TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES
HHERE STATE L~H REQUIRES that tile Electrical work be done by an Electrical Contractor, the electrical portion of this permit
shall not be vali1 until the label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXMIINED the completed application for permit, and do hereby certify that all information hereon is true
and correct, and I further certify 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 OCCUPAr~CY will be made
of any structure without the permission of the Building Division. I further certify that my registration with the Builderts
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
only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project.
IWIE(please print)<----r;;",,f" '1 13 kll'v'e, ( ( SIGrIATUR- gJ," .', l2A~d /
, FD~ OFFICE US~
Tyoe/Const. Tl' -A./ Units / Sq. Ftg. Ilain
Bedrooms - Occy Load Sq. Ft9. Access;1I.1'!,sn x
Stories J Occ,y Group 114- / Sq. Ftg. Other
DATE9;:;zr-rl
Zone
R-J
x
Value
Value
Value
TOTAL VALUATION,
/dcoOJ
Fire Zone ,.,.--,
Flood Plain 111'1)
x
BUILOING PER~1lT n____./~'cn Plan Ck. Comm/Ind Shsterns Development
Charges an~ 65~/Rldo ~~r F~~ C arqe (J, 5%)
Surcharges I ;,IR' Plan Ck. Res It..O t?c
30t/Bldo Per Fee 6.- 6 ,'f-~iHJ
PLU'1BING PERMIT Fence BJ,.,PS73.39 I
Charges and ------------
Surcha rges Detno I I
ELECTRICAL PERI~IT 'Sidewalk I I
Charges and ------------
Surcharges A/C Pavin~ ITotal Comb. rermit
MECHANICAL PERMIT I Cu~.b Cut I ~c:o? '15\"
Charges and ------------ I I TOTAL
Surcharges
tf s'tj ,<.!/
/7-03- -Sq - 11.
7' t. 3s-oCJ
.
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
i
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1 II.
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1
I. Appl leant to furnish
A. Job Address
B. Legal Description
1. example- Tax Lot 100. lane County Map Reference
11 oj 43
2. exame]e. Lot I. Block 3, 2nd Addition to
Springfield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. examole- heat/electrical ceilinQ/or forced air Qas
2. examyle- waterheaterjelectrlcal/or 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. examole - construct single -~cimily house ~ith an
attached garage
2. examole - remodel existing garage into (amily room
3. example - convert single family residence into
restaurant (change of use) .
G. Value of work as defined in Sec~ion 303 (a)!uf the
Structural Specialty Code .
H. OESIGN TEAI.I ANO CONTRACTORS
To avoid design or C(':13truction delays, Building
Division Staff must b~. ~ble to contact appropriate
persons regarding desiqn "informat"ion or job "site
corrections, etc. '
Abbreviated Plumbing, Mechan'i~al, & Electrical S-chedu'les
A. Except where blank spaces occur 'in the description
portion of the Mechanical and Electrical Schedules,
the app 1 i cant need fi 11., i n on 1 y the No. Boxes adjacent
to the appropriate item(s) to be installed ".
B. Full Plumbing, Mechanicc:.-I \ and Electrical Schedules
are available at the ~uilding 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. BUILOING OIVISION STAFF WILL FILL OUT ALL FEES ANO
CHARGES ON THE SCHEOULES
D. As noted on the CAP. the 1 abe 1 mus t be deli verecj' to the
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.
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V. FOR OFFICE USE ONLY
Pennit Clerk
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110101 ..
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PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Infonnation:
. , .
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/2
" ~ ~r
date
9--2q';..%7
PLANS REVIEWED BY:
name
signature