HomeMy WebLinkAboutPermit Building 1980-4-25
1 INSPECTION LIln,
726-3769
Job Address /,?{ 0'2.-/6'V>4/ ~/AI<.t
legal Description ~}-l\.
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CITY OF SPRINGFIElD
COMBHIATlON APPLICATION/PERMIT
E!IERGY SOURCES:
Heat
Ua ter Hea ter
,
INFORlIATlON UNt
726-3753
Sq, Ftg, 1,Iain
~q. Ftg. Access.
So, Ftg. Other~~
lie" Add Alter Pep,
=-Fenc~ Oemo_Change/Use
Q"utner'" ')
0,,(>,
Ran!le
Owner fA / L L
Address '7:3 i
Phone? ~t'2"1)>
Va 1 u'(!)7r'}tf') cD
BuiltiinQ f'ermit Info: Describe \~ork{ i..e..
Famil v l1es i dence l-Ji th .A.ttached Ga raQe)
Build Single
lname)
Phone
(address )
)~~~
(j)
Construction lender
NCI'N?
Address
Ut,lGII I tAI1
(lies. no.)
(exo;res)
(OhOM no.)
Primary
Structura 1
Electrical
11echan; ca 1
CONTRACTORS (name)
(E:, 0 b
{address 1
(1 ics. no.)
(p.xnir~c;)
(ohane no.)
General
-l- A Iv? Fs
/7"L.pP
7Y-? kOtJ.b
Plumbina
Electrical
A U!,ut/f'/J If
,['..t./r'" C 77Z/U/ t
c..C/./ '/,,('.41:: tck '"
~lechan; ca 1
PlUllBlIlG
ElECTRICAl
MECHANICAl
NO,
FEE CHARr;F NO
~~~ rH~. NO_
'TI-1J:lJARGL
So' FT,
furnace/burner to
BTU's
Each single fixture
Residence of
Relocated building
(new fix. additional)
S.F. Residence
(1 bath)
Ouplex (1 bath) each
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
~na~p hp~tpr Anrl vpnt
Sewer
ITempOrary Construction
IChange in existing
rp'iiqenr.p,
ImUltifamily. COlTlll. or
Tnnustrial
IOf amps,l
ICOffi1,/IND. FEEDERS I
IInstall/alter/relocate I
rli(;trih fpprlpr(;
IOf amps.1 I I
\1 I 15 LX.) I
I I
I
I App 1 i ance vent
c;poaratp
I Stationary evap.
cooler
I Vent fan with
sinale duct
I Vent system apart
heatinq or A.C.
I Mechanical exhaust
hood and dur.t.
I \'}ood stove/heater
I
I
I
from
Additional bath
~Iater service
Storm Sewer
ISSUANCF OF PFR!IIT
TOTAL CHARGES TOTAl CHARGES TOTAl CHARGES
WHERE STATE L\H REQUIRES that the 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 Surervisor and returned to the Building Division
I HAVE CAREFUllY EXM1INED 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 llO OCCUPAIlCV 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 ons 701.055, that if exempt the basis for exemption is noted hereon. and that
only subcontractors and employees who are in compliance with ORS 7~I.055 will be used on this project.
I~AI.IE (p 1 ease print) IAr/l1-/A ../{ .?MntPY SIGIIATURE~~9~ OATE U ~?<l1
FOP. OrFICE USE QlllY
ZonE' Tyoe/Const. Units Sq. Ftg. r1ain x Value
Fire Zone Bedrooms Occy load Sq. Ftg, Access x Value
Flood Plain Stories Occy Group Sq, Ftg, Other x Value
TOTAl VAlUATION
BUIlOING PER~1lT
Charges an~
Surcharges
_~u-,~r:::L ~~~~o~~;
C'/'/, Plan Ck,
N } 30%/Bldo
Fence
COIlllll/! nd
pOI'" Fee
Res
Per Fee
Systems Development
Charae (1.5~)
I
I
I
I
I
I
I 6lo.L\O
PlU'1BING PERMIT
Charges and
Su rc ha rl}e s
ElECTriCAl PERlm
Chijrges and
Surcharges
11ECHANICAl PERI1IT
Charges and
'll'"charc1es
Demo
__l~-,-~_<?_u Sidewalk
,loC') A/C Paving
~-----------l Curb Cut
Total Comb, rermit
. Tt'l,ul
,
.
,. .~-.
..
,
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Applicant to furnish
A, Job Address
B. legal Description
1. example- Tax lot 100. lane County Map Reference
1I 03 43
2, example- Lot 1. Block 3. 2nd Addition to
Springfield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. examp.le- heat/electrical ceiling/or forced air oas
2. example- waterheater/electrical/or solar
E. Square footage or valuation, etc. -
1. examole- 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 TEAl-I AIIO 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. Nechanical, & 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. 1f 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 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.
I
V, FOR OFFI CE USE ONLY-
Permit Clerk
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project InfDnnation:
PLANS REVIEWED BY:
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name
signature
date