HomeMy WebLinkAboutPermit Building 2011-8-22
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Structural Permit Application
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225 Fifth Street. Springfield, OR 97477. PH(54 1)726-3753 . FAX(541)126-3689 ../:..; .... ~-'
DEPARTMENT USE ONLY
Permit no.: 511-/1??
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Date:
This permit is issued under OAR 918-460-0030. Permits expire if work is not started within 180 days 0
suspended for 180 days.
LOCAL GOVERNMENT APPROVAL
This project has llnalland-use approval.
Signature: Date:
This project has DEQ approval.
Signature: Date:
Zoning approval verified: 0 Yes 0 No
within Oaod plain: 0 Yes 0 No
. CATEGORY OF CONSTRUCTION
o Government
JOB SITE INFORMATION AND LOC
Job si{e nddress: C
City:
Subdivision:
Reference:
ZIP:
PROPERTY OWNER
Name:
ZI
City.
Phone'
E-mail:
This installation is being made on residential or Carm property owned by
me or a member army immediate rami!)'. and is exempt from licensing
require r 701.010.
Address:
City:
Phone:
E-mail:
CCB license no.:
Print name:
State:
Fax:
ZIP:
Signature:
SUB-CONTRACTOR INFORMATION
Nllme cell License Number Pholle Number
Electrical
Plumbing
Mechanical
FEE SCHEDULE
1. Valuation information
<aJ Job description: tf!ETyn tV/1V7 t-J ~ i-f-
Occupancy u....
Construction type: v1(
Square feel:
Cost per square foot:
Other information:
Type or Hcat:
Energy f::ltb:
C}rt'Cw o II Iteration o nddilion
(b) Foundation-only permit? DYes DNa -
TotDI,"'alllation: $/!;lJO
2. BulJding fees .,
(a) Permit fee (use valuation table): $ c.li'_
(b) Investigative fee (equal to [21l)): $
(c) Reinspection ($ per hour): $
(number of hours x fee per hour)
(d) Enter 12% surcharge (.12 x f2a+2b+2cl): $;';~
(I:) Subtotal offccs above (211lhrougb 2t.1): $
3. Plan review fees
(a) Plan review (65% x permit fee [201): $
(b) Fire and life safety (40% x permit fee [2a]): $
(e) Subtotal offees abo\'e (33 and 3b): $
4. Mis('ellnueous fees 2~~
(a) Seismic fee, ]% (.01 x permit fee l2a]): $
TOTAL fees and surchllrges (2c+3c+43): $ (g,? ~c.
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. '\ OREGON
TRANSACTION RECEIPT
CITY OF SPRINGFIELD
225 Fifth 51
Springfield,OR 97477
541-726-3753
www.cLspringfield.or.us
811-5PR2011-01977
241 5 C 5T
pe nnitcenter@cLspringfield.or.us
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. ACCOUNLCOOE
821-00000-215004
224-00000-425602
100-00000-425605
TOTAL DUE:
DATE: 08/22/2011
AMOUNT.D.UE
6.96
58.00
2.90
67.86
AMOUNT PAID
67.86
RECEIPT NO: 2011002287
lOE5.CRIP-TION
State of Oregon Surcharge (12% of applicable fees)
Structural BuildingJ>ermit Fe:
__ Tech~l?gy fee. (5% of permit total)
RECORD NO: 811-SPR2011-01977
LP.A'l'rvIENJ..clyei::-"---___e&OR CASHIER: CCARPENTER.
Cash Byan Lauber
_C.OMMENT.S
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TOTAL PAID:
67.86