HomeMy WebLinkAboutPermit Building 1980-9-15 (2)
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Job Address Z- L -'[ 9i If( (,)5Qht lI)'> S-<'k!-
legal Description ~
INSPECT ION L1IIE
726-3769
CITY UF SPRIilGFIELD
COIIBlilATION APPLICATION/PERMIT
E:lERGYr SC\lJR~~
Heat Ill,
!'/ater Heat~r
Ranqe
Address '-~ G_t"-v'\ 0
Phone
INFORllATION LlNl
726-3753
Sq. Ftg. Hain
~q. Ftg. Access.
Sq. Ftg. Other
r~e\oj Add Alter P.ep.
--Fence Demo Change/Use
va140(5k.:OD Other--
Bullriino Permit Info: Describe \'lork(i-.e., Build Single
Family P.esidence With Attached Garaae)
1) II 0 (lm:'vi 1 I ~ mO<::j~( JJ!
I r ,Ao d.i -=<;~ ) I
.
100
8
00
\)Q.
(j.
Owner
LoIS
Br-en t-
I Cf (f)- I 4~~
Construction lender
Address
Ut~lliN Ti:.Ar-1
lname)
Phone
(addressl
(lies. no.)
(exnires)
(ohone no.)
Primary
Structural
Electrical
!1echanical
CONTRACTORS (name)
Genera 1 f"\ I 1 ')./) Q Jr<::"
(address)
yrft()~
(lies.. nn.)
(exoires)
(Dhnn~ nn_ )
I Plumbina
Electrical
Hechanical
PLUIIBlIIG
ELECTRICAL
MECHANICAL
NO.1
lEaCh single fixture
[Relocated building
(new fix. additional)
IS. F. Res i dence
(J bath)
D"plex 'I bath) each
FEt rHAR~F NO
1="1="1=' nlARr,1=" NO.
1="1='1=" njAR(;1="
Residence of
SQ. FT.
furnace/burner to
BTlI's
New circuits alts.
or extensions.
Floor furnace
and vent
ISERVICES
Recessed wall
Sn~rp hp~tpr ~nrl vpnt
Storm Sewer
Of
amps,
Appliance vent
seoarate
Stationarv evap.
cooler ~
Vent fan wi th
sinole duet
Vent system apart from
heatina or A.C.
Mechanical exhaust
hood ilnd durt
Additional bath
Sewer
Temporary Construction
IChange in existing
res,i d~nq'
multifamily, camm. or
fnduc:.triill
~!ater service
C0I11-1. II NO. FEEDERS
Install/aJter/relocate
dic:.trih. fppdprc:.
Hood stove/heater
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I ISSUANCf OF PFRtIIT
TOTAL CHARGES I TOTAL CHARGES I TOTAL CHARGES
~IHERE STATE L'H REQUIRES that the Electrical work be done by an Electrical Contractor, the electrical rortion of this pernit
shall not be valiJ until the label has been signed by an Electrical Supervisor and returned to the BUilding Division
Of
amps.1
"-
I HAVE CAREFUllY EXN1JrlED the completed ap!"l icat;on for permit, and do hereby certify that all information hereon ;s 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 -l.'I'ork described herein, and that rw OCCUPAUCY will be made
of any structure without the permission of the Building Division. I further certify that my registration with 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 th~t
only subcontractors and employees who are in compliance with OP.S 701.055 will be used on this project.
IIAf.IE(please print) .+-- ,"; ,"" K (""" e '''+ SIr,il^TURE~t---V:-, (3A_.~_,-i-
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FOr. OFFICE USE O:IL Y
om '1'- is- go
Zone
Fire Zone
Flood rl~in
Type/Canst.
Bedrooms
Stories
Units
Ocey load
Occy Group
Sf!. Ftg.
Sq. Ft!).
Sq. Ftg.
tlain
Access
Othe r
x
x
Value
Value
Value
x
TOT^,L VALUATION
BUILDING PERI.IIT
Cha rges an~
Surcharges
CorranlInd
Per FeF:'
Res
Per Fee
Systems Development
Charqe (1.5%)
PLUt1BING PERMIT
Charges and
Surcharges
IIECHANICAL PERI11T
Charges and
Surcharges
Curb Cut
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Total Comb. rerm~_..l..
TOTAL . Lt._~. VJO
ELECTRICAL PERI~IT
Charges and
Surcharges
'":'"".:.' '., ....
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A. ..-.. -~:.;.' .:
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COMBINATION APPLICATION/PERMIT (CAP)
I.
~.
PERMIT VALIDATION
II.
Applicant to furnish
A. Job Address
B. Legal Description
1. examole- Tax lot 100, lane County Hc.
17 03 43 (,'
2. examole- Lot 1. Block 3, 2nd Additic
Springfield Estates
C. Name, etc. of owner and construction len
D. Energy Sources
1. examole- heat/electrical ceilinq/or
2. examole- waterheatertelectrical/or s'
E. Square footage or valuation, etc. -
1. examole- 1250 sq. foot house, 500' sq ~O,'
2. example- if new project, check-new _ \
check add. etc.
F. Building permit information:
1. example - construct single family hOl C'"
attached garage .
2. examole - remodel existing garage int
3. examole - convert single family resic
restaurant (change of use)
G. Value of work as defined in Section 303
Structural Specialty Code
H. OES I GII TEAr.j AllO COIITRACTORS
To avoid design or construction delays, B ~-r'
Division Staff must be able to contact ap ~
persons regarding design information or j
corrections, etc.
Abbreviated Plumbing, Mechanical, & Electrica ,rl:
A. Except where blank spaces occur in the de. \n
portion of the Mechanical and Electrical:
the applicant need fill-in only the No. B(
to the appropriate item(s) to be installec "
B. Full Plumbing, ~lechanical, and Electrical \er'
are available at the Building Division
1. To conserve space on the permit form t
have been abbreviated
2. If the item(s) to be installed are not (p
the abbreviated schedules you should c
full schedules
C. BUILDU/G OIVISIo;/ STAFF WILL FILL OUT ALL
CHARGES 0;/ THE SCHEDULES
D. As noted on the CAP, the label must
electrical contractor for signature
supervisor. The general contractor
to sign the electrical label.
Applicant to sign and date
Whenever possible, the initial application wil'
a worksheet only. Where possible, Building Oi,
will prepare a type written copy and return it
applicant at the time the actual permit is iSSl
signature.
Fees and Charges
Plan check fees are due and payable at the time. it
application. and no plans wlll be processed unt
fees are paid. All other fees and charges are k... .."",- -
payable when the permit is issued.
!I.S"'. (.
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SPRINGFIELD
OF
CITY
c
City Hall
Springfield. Oregan
Department of Public Works
OFFICIAL RECEIPT
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S4575(
Date q -, ~
Rec'd From /....DLS
Address ZZl f)
191J!)O. 'B
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Received For: U
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C Amount Received 1 ~ ~_ (n CJ (
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-I' AUTHOl'ln:l!:O !lIGi'lATURE
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V. FOR OFFICE USE O:Il/Y
Permit Clerk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPArlCY:
Permit applicant exempt from registration with the Builder's Board because:
~
j Additional Project Information:
1
,
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PLANS REVIEWED BY:
name
signature
date