HomeMy WebLinkAboutPermit Mechanical 4-5-16
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RESIDENTIAL
PERMIT APPLICATION
LOT:
O~NER: (JQ'<\ f\
ADDRESS' ~ \ 4~ \
CITY: ~~ l~.i)
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DESCRIBE WORK:\=--l
NEW REMODEL
CONTRACTOR'S NAME
GENERAl. ,
PLUMBING: )
MECHANICAL:10. i~
ELECTRICAL:
BLOCK:
ADDITION
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JOB NUMBER
q4{)J~!L
J
TAX LOT:
SUBDIVISION:
~l(o
ADDRESS'
CONST,
CONTRACTOR #
PHONE
EXPIRES
: ~
- OFFICE USE -
QUAD AREA- ~ LAND US.,::. FLOOD PLAIN:
# OF BLDGS: # OF UNITS' ZONING CODE:
OCCY GROUP: CONSTR. TYPE: ". OF BDRMS:
# OF STORIES: HEAT SOURCE: SECONDARY HEAT:
WATER HEATER: RANGE: SQUARE FOOTAGE:
To request an Inspection, you must call 726-3769. This Is a 24 hour recording. All Inspections requested before 7:00 a,m, will be
made the same working day, Inspections requested after 7:00 a.m. will be made the following work day,
o Temporary Electric
o Site Inspection - To be made
after excavation, but prior to
setting forms.
o Underslab Plumblng/Electrlcaf/
Mechanical - Prior to cover.
o Footing - After trenches are
excavated.
o Masonry - Steel location, bond
beams, grouting,
o Foundation - After forms are
erected but prior to concrete
placement.
o Underground Plumbing - Prior
to filling trench.
o Underfloor Plumbing/Mechanical
- Prior to Insulation or decking,
o Post and Beam - Prior to floor
Insulatlon or decking,
o Floor Insulation - Prior to
decking.
o Sanitary Sewer - Prior to filling
trench.
o Storm Sewer - Prior to filling
trench.
o Water Line - Prior to filling
trench.
o Rough Plumbing - Prior to
cover.
REQUIRED INSPECTIONS
o Rough Mechanical - Prior to
cover.
o Rough Electrical -,. Prlo~ to
cover.
.
o Electrical Service - Must be
approved to obtain permanent
electrical power. '
o Fireplace - Prior to facing
materials and framing Insp.
o Framing - Prior to cover.
o Wail/Ceiling Insulation - Prior to
cover.
o Drywall - Prior to taping.
o Wood Stove - After Installation.
o Insert - After fIreplace approval
and Installation of unit. '
o Curbcut & Approach - After
forms are erected but prior to
placement of concrete.
o Sidewalk & Driveway - After
excavation is complete, forms
and'sub-base material In place.
o Fence- When completed.
o Street Trees - When all required
trees are planted.
o Final Plumbing - When all
, plumbing w9rk Is complete.
o Final Electrical .,.-- When all
electrical work Is complete,
~
o Final Mechanical - When all
mechanical work Is complete.
o Final Building - When all
required Inspections have been
approved and building is .
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MOBILE HOME INSPECTIONS
o Blocking and Set-Up - When all
blocking Is complete.
o Plumbing Connections - When
home has been connected to
water and sewer.
o Electrical Connection - When
blocking, set-up, and plumbing
Inspections have been approve<;1
and the home is connected to
the service panel. '
o Final - After all required
Inspections are approved and
porches, skirting, decks, and
venting have been Installed, '
BUILDING PERMIT
ITEM SO. FT. X $/SO, FT.
Main
Garage
Carport
Total Value
Building Permit Fee
State Surcharge
Total Fee
(A)
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Setbacks
HSE GAR ACC
VALUE
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SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
PLUMBING PERMIT
ITEM
Fixtures
Residential Bath(s) NO
Sanitary Sewer FT.
Water FT.
Storm Sewer FT.
Mobile Home
Plumbing Permit
State Surcharge
Total Charge
(C)
MECHANICAL PERMIT
Furnace
Exhaust Hood
Vent Fan
NO
Wood Stovellnsertl Fireplace Unit
Dryer Vent
Mechanical Permit
Issuance
+ .45
State Surcharge
Total Permit
(D)
MISCELLANEOUS PERMITS
Mobile Home
State Issuance
State Surcharge
Sidewalk
ft
ft
Curbcut
Demolition
State Surcharge
Total Miscellaneous Permits (E)
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, D, and E Combined)
FEE
I~CO
- () CXJ
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,1-5
OkS. '7S
LUQiV
( J THE PROPOSED WORK tN THE _
HISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTER?
If yes, this application must be signed
and approved by the Historical
Coordinator prior to permit Issuance.
APPROVED:
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit Is granted on the express condition that the said
construction shall, In all respects, conform to the Ordinance
adopted by the City of Springfield, including the
Development Code, regulating the construction and use of
buildings, and may be suspended or revoked at any time
upon violation of any provisions of said ordinances.
Plan Check Fee:
Date Paid:
Receipt Number:
Received By:
Plans Reviewed By
Date
Systems Development Charge Is due on all undeveloped
properties within the City limits which are being improved.
ADDITIONAL COMMENTS
By signature, I state and agree, that I have carefully examined
the completed application and. do hereby certify that all
Information hereon is true and correct, and I further certify
that any and all work performed 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 OCCUPANCY will be made of any
structure without permission of the Building Safety Division,
I further certify that only contractors and employees who
are In compliance with ORS 701.055 will be used on this
project.
I further agree to ensure that all required Inspections are
requested at the proper time, that each address Is readable
from the street, that the permit card Is located at the front
of the property, and the approved set of plans will remain
on the site at all times during construction.
SignalU~~A.-.--
Date .4\'-/' - 9'1
::~:;:MBER \~~~
DATE PAID (~, \ to '.q _
AMOUNT RECEIV(E_~ a ~ .~o
RECEIVED BY ---f7\C~
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Permit No: C\40lctf" ~ -
Address: ~_~_JJ1~f\ ~9\lJQ_-:(
Issued by:~[)n_) Date: gJ ..ffo-~'
FOR OFFICE USE ON L Y
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement will be
fi led with the permit.
Fill ip, t~plicable blanks, and initial boxes 1 and 2, and either box 3A or 3B:
1. N--{ I own, reside in, or will reside in the completed structure.
I
2. I \
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
3. A.I
I My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR r \ CV
3. B(//)II will be my o~~~QlUI'
If I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. If I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor.
I hereby certify that the above information is correct and that I have read and understand
the Information Notice to Property Owners about Construction Responsibilities on the
rev e side of this form.
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nature of Permit Applicant
S-/t,-?o/'
Date
CO~STRUCTION CONTRACTORS BOARD
024~ 8/91
WHITE COpy TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
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INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
N~E_ This IflfQrmatio!, Notice to Property Owners About Construction Responsibilities,
" was dev~loped by the Construction Contractors Board in accordance with ORS 701 :055(5),
pas!?ed by tl:1e 1989 Oregon Legislature. ' " >, ," ,
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, tlf you :~re acting as your oWn contractor'-'to 'con~truct anew home or make a substantial improvement to an
; existing structure, y<;>u can prevent lTIany problems by being aware of the following respon.sibillties and areas
'of concern. . ..., " , , ,,',:, ',- '
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EMPLOYER RESPONSIBILITIES::
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If you hire persons not registered 'with tl1e C,onstruction Contractors Boarq to do labor in constructing or assisting
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in the constructi6n_ori~provem;tjntti(~r~sid,~ntia~'struc~ure; you wi,lI,'in mostinstaflces, beruled to be an
"employer" and theReopl~ ybu~ire.will b~ "employe'es',':;As :the ~mp:16yer; yo~must comply with 'the following:
'. .' , ..,. " . " .' .- '... ,.
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Oregon's Withholding 'T~xt-aw: "Asan employer, YOu,M~st wit~hold)ncome iaxesfrom employee wages at
the time employees are:paid, You will b.e IlabJe JQr; th'e tax payrpe:nts even if -you don~t actuaily withhold the
tax from your employees. For more'information, call the o reg'on , Depart,ment of ,~evenue ~t 378-3390.
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Unemployment Insurance Tax: As an employer, you are' required to pay a tax for unemployment insurance
purposes on the'wages, of all ,er;npl.oye~s.,:F(>.rmore infornl~tior!', caJl the Or;egon Employment Division DHR
at' 378-3224.
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Workers' Compensation Insurance:, As an. employer, yoU' are subject to the 0r:egon Workers' Compensation
Law,and must obtain workers' compensation insurance for your employees. , If you fail _to obtain workers'
compensation,insurance, you maybe subject to penalties andviJiII be liable fo(all c1aimc<;>sts if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 373-7434.
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U.S. Internal Revenu.e Servic.~: />:S ~n.empI9yer, y.ou mU~!"'!~tb~old,f~q~r~l,in.~om,e tax from employees' wages.
You will be liaole~f6'dhe t~x .pi!yment even if. you' didn't, ~c.t!J~"Y wimholq 1he tax. Fo~ ,more information , call
the Internal Revenue Service at 221-3960.' , . "0' ,.". - , .
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OTHER RESPONSIBILITIES AND AREAS OF CONCERN.:; : ,; . '~., ",
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Code Oompliance: As the p'ermi~ hoJdeHocthis,pr9rect,~yoo are,s:esponsible for resolving any failure to meet
code requireme~ts.that may be.br?ught to:your attention throtighibspections. "
, , - :-;.
Liability and Property Damage Insurance: ~Contact your insurance ag'en1'to see'if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint overspray;water da'mage from pipe punc-
tures, fire, or work thatf'!lust be re-done.
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Time t6: Supervise Employees: Make sure'yo,uhave 'suffic1e'1t'time to,supervise you~ ,e~mployees.
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Expertise: Make sure you have"the experti~e to act as your own general contractor, to coordinate the work
of 'rough-in a~d finish. !r,ades, arid to notify building officials at the appropriate times so they c~n perform
.Jhe required inspections:': . 'I."; '!','. . "
If you have additional que,stions, write to:
Construction Contractors Board
700 Summer. St NE, Suite, 300
Salem, OR '97316~0151' ,
Phone 503-378-4621
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...: 0244J10/24/89:'
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