HomeMy WebLinkAboutPermit Sewer Connection Record 1981-3-17
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INSPECTION LINE
726--3769
Job Addr!!u
Conuruclion lender
Add,.n
cln OF SPRINGfielD
CO,~~jNJi.H~N APPLICATION/PERMIT
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INFORMATION LINE
726-3753
I ENERGY SOURCES:
Hec"
Waler Heater
Range
Yalve of Work:
, Sq. FIg- Main
Sq. FIg. Aceltll.
Sq. FIg. Other
_Ne......_Add__Altor_Rep.
__ _Fonce__OQmo_Changel Uso
__Other
n (h
- -B'vildin9'.P~;~il I"f; Describe Work (i.e., Build Sing I.
Fomjlv;if!~idi!!"c'! With Attachod Gorace)
~ J jJ} Jr } ~ALbVl )
:.-
phone
(addreu)
Primary
DESIGN TEAM (nome) I /""
(umJJfr1JiJy) ().MLJ(j
Structural
Electrical
Mechanical
CONTRACTORS
(nome)
Gllnorel
PlumbirlC:j
electrical
Mechonicol
PLUMBING
I
CHARGE I
NO.1
I
I
I
I FEE
I
I
I
I
I
I I
boO ? Ni)
I
i
Each sinqlc fi}lture
Relocated building
(new fix. additional)
S.f. Residence
(1 balh)
I
I
I I Water ,ervic!:
I?DC. Sewer
I
I
I
I
I
I
r
I TOTAL CHARGES
I
Dualelll (I balh) each
Additional bath
Storm Sew~r
WDO
WHERE STATE LAW REQUIRES that the Electrical worle be done by the Electrical Contractor, the electrical portion of this permit shall nol bo valid until 0
label has be.n signed by on Electrical Contractor and attached 10 the electrical panel.
(lies. no.)
(ekpires)
(phone no.)
y!)>
J'
A
vJ
I
I
I
I
FEE
'CHARGE I
(address)
Wcs. no.)
(upir!!s)
(Dhone no.)
I HAVE CAREFULLY EXAMINED the completed application for permit, and do hereby certify that 011 information hereon is true and correct, ond I further
cerrify that any and all worlt performed sholl be done in accordance with the Ordinanclls of the City of Springfield and the laws of the Slat. of Orogon
pertaining 10 thl!' work described herin, and lhat NO OCCUPANCY will be made of any structurl!' without thll permiuion of the Building Division. I further
certify that my regisrrotion with the Builder's Boord is in full force ond effect os required by ORS 701,055, that if eJtempt the basis for ekemption is' noted
hllron, and that only subcontractors and employllOs who ore in compliance with ORS 701.055 will be used on this project.
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SIGNATURE ( r;f~
Basis for Builder's Boord llkllmptiar'"
NAME (plcose print)>l.Jt 0 hI Q <
('"
Zon-
Fire Zone
Flood Plain
Type/Canll.
Bedrooms
(,toric'
BUilDING PERMIT
Charges and
Surcharges
PLUMBING PERMIT
Charges and
Surcharges
(1).00
,Y{)
C(07n
ELECTRICAL PERMlf
Charges and
Surcharges
MECH....NICAl PERMIT
Charges end
Surcharges
ELECTRICAL
MECHANICAL
NO. I
I CHARGE
FEE
NO.
Residence of
furnace/burner to
BTU's
Appliancll vent
separoto
Stationary evClp.
cooler
Vent fan with
sinClte duct
Vent system apart from
heotinq or A.C.
Mechanical okhault
hood and duct
~q: ft.
New (ircuih, alterations
or extensions
SERVICES
Temporary Construction
Amps.
Wood slove/healer
FEEDERS
Hoot PumD
Air handler to
10.000 CFM
Air ho~dler oVllr
10,000 CFM
Amps,
ISSUANCE Of PERMIT
TOTAL CHARGES
TOT Al CHARGES
,\'ovl~
('"e,L
DATEY- 3 - 17-8 (
FOR OFFICE USE ONLY
Units
I')ccy Load
''1ccy Group
Sq. Ftg, Main
Sq. FIg. Aceeu
Sq. Fig. Other
Value
J( Value
Ya/u.
TOTAL VALUATION
PIon n. Comm/lnd
65%1 Blda Per fee
Plan Ck. Res
30%1 Bldq Per Fee
Systems Development
Chorae (1.5%1
Fence
Demo
Total Comb. Permit
Sidewalk
Alc Povina
Curb Cut
TOTAL
COMBINATION APPlICATION/P.IT (CAP)
I. Applican.( to furnish
......
A. Jab Address
B. Legal Description
1. example-tax lot 100, Lane County Map Reference 17 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. example.heat/electrical ceiling/or forced air qas
2. example-woter heater/electrical/or solar
E. Square footage or valuation, etc.
1. example-1250 sq. fOOl house, 500 sq. foot garage
2. example-if new project, check new-if addition, check
odd. 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 TEAM AND CONTRACTORS
To ovoid design or construction delays, Building Division
Stoff must be able to contact appropriate persons regarding
design informction or job site corrections, etc.
II. Abbreviated Plumbing, Mechanical & 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 adiacent to the appropriate
item(s) to be installed
8. Full Plumbing, Mechanical, and Electrical Schedules
are available at the Building Division
1. To conserve space on the permit form the schedules
hove been abbreviated
2. If the item(s} to be installed are not covered on the abbrevi-
ated schedules you should consult the full schedules
C. BUilDING DIVISION STAFF Will FilL OUT ALL FEES AND
CHARGES ON THE SCHEDULES
III. Applicant to sign and date
Whenever possible, the initial application will be used os a
worksheet only. Where possible, Building Division Staff will
prepare a-typewritten 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 du; 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.
V_ FOR OFFICE USE ONLY
PROJECT CONDITIONS TO BE SATISFIED BEfORE OCCUPANCY:
Additional Project Information:
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PLANS REVIEWED BY,
nam'"
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signatur...
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Permit Cler~
PERMIT VALIDATION
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