HomeMy WebLinkAboutPermit Sewer Connection Record 1981-3-17 (2)
INSPECTION LINE
726-1769
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..;; r..ITY OF 5PRINGFIElD
CCl:INAtrON APPLICATION/PERMIT
INFORMATION LINE
726.-3753
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I ~ Q 4 ~/"\ rLn () /," "i--. . A ENERGY SOURCES, .' Sq. "g. Mo'n
Job Addren . ( ) /) tlJUA.,....J.A.-t.J U-/Lf....U Heat Sq. Ftg. Accen.
/} Waler Heater Sq. Ftg. Other
Legal O",criplian . Ronqe _New. _Add__Alter _Rep.
~Ji .J,.,~pl ctn C v I va'.. of ':'0,1, 1--,.n,,__o.mo_Chong./U..
l)wn" lOrY I 0 V -r .--'JQ bI:to--vl (V\ ~ __ _.__ _ _ __ _ __O,h.,
r.a (J ('\ lo-{n BUllding.Permillnfo: Oe$Cribe Work (i.e.. Build Single
Addre" '1 I ^ ~ ' / ../ Phone FamilvlJ!..""irl"".." Wilh Attached Garaael
. JLI.i ifl)r ) ->>t:.t.u1 AUJvt )
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I Construction Lender
I Addren Phone
j OESIGN TEAM (nome) I. r::
I p,'mo,. (JJmj) /)fJJJ!irV} f /. !J.M(,
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Structural
I Electricol
I Mechanical
CONTRACTORS
General.
Pll.lmbinQ
Electrical
Mechanical
PLUM81NC
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Izcc
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Each linqle fi",hm!
Relocated bl.lilding
(new fix. oddilionol)
S.f. Residenc.
(1 bathl
Ouolu (I both) each
Addilional balh
Waler 1erv;ce
Sewer
Storm Sew..,
,.
TOT AL CHARGES
J'
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vJ
(addre,,)
(Ii". no.)
(phcme no.)
(upirel)
(name)
(addren)
(expireS>
(phon& no,)
Wet. no.)
ELECTRICAL
MECHANICAL
fEE I CHARGE NO.
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110.00 ;7 (\wl
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( CHARGE
I
ICHARGE i
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NO. I
FEE
Residence of
_Sq:ft.
New circl.lih. olterotio"s
or extension I
fl.lrnace/ burner to
"'TU'I
Appliance V"",
IOoorolo
Stationary ....ap.
cooler
Vent fan with
,inqle duct
Vent system opon from
hel:ltina or A.C.
Mechanical Ollhault
hood and dl.lct
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..1
SERVICES
Temporary Conltruction
Amps.
Wood Iloveiheoler
FEEDERS
Heat Pl.lmp
Air handler to
10.000 CFM
Air ha;:;dler over
10,000 CFM
Amp1.
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WDO
ISSUANCE Of PERMIT
WHERE 5TATE LAW REQUIRES that th. Electrical work be done by the Electrical Contractor, the electrical portion of this permit .hall not be valid until 0
label has bee" signed by on Electrical Contradar and CI"ached to the olectrical panel.
I TOTAL CHARGES
I HAVE CAREFULLY EXAMINED Ih. completed application for permit, and do hereby corlify that all information hereon il Iru. and correct, and I fl.lrth.r
cerrify that any and 011 worll performed sholl be done in accordance with the Ordinances of the City of Springfield and the LOWI of the Sloto of Oregon
pertaining 10 the work delcribed herin, and that NO OCCUPANCY will be mode of any url.lcture without the permiuion of the 51.lildin9 Civilian. I fl.lrther
certIfy that my regi5tration with the 8l.lilder's Board is in fl.lll force and effect as required by ORS 701.055. that if exempt ,he basil for .Jll:emption is' noled
h.ron_ and Ihal only lubcontraClatJ and employees who are in compliance with ORS 701.055 will b. used on this project.
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SIGNATURELr;f~
fOR OFFICE USE ONLY
TOTAL CHARGES
Sosis for Bl.lilder's 80ard exemption-
NAME (pleale print) ~-rt; 0 h I a 0::
Zone
Fire Zone
Flood Plain
BUILDING PERMIT
Charges ond
Surchorges
PLUMBING PERMIT
Charges and
Surcharges
tqOJn
ELECTRICAL PERhUT' .
Charglls and
Surcharge I
MECHANICAL PERMIT
Charges ant
Surcharge.
('- .
S~-OLJ '-
('.,'~I-L
om:x3-17-8(
Typel Canst.
~draom.
~tarief
Sq. Ftg. Main
C;q. Fig. Accen
Sq. Fig. Other
Unih
f"lccy Load
""'cy Grol.lp
x
"olue
Volu.
Voll.lll
x
x
TOTAL VALUATION
Plan CIt. Camm/lnd
65%/ Bldo Per Fee
Plan Clt. Res
30%1 BldQ Per Fee
Sy1tems Development
Charae 11.5%1
'1D.OO
.Y{)
fence
Demo
Total Comb. Permit
Sidewalk
Ale PevinCl
Cl.lrb Cl.lt
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TOTAL
..._...~~
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Fees and Charges III
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 ore due and payable when the permit
is issued.
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COMBINATION APPLICATION/_lIT (CAP)
I. Applicanl to furnish
A. Jab Address
B. Legal Description
1. exomple.tox lot 100, Lone County Map Referenl
2. examale-lat 1. Black 3, 2nd Addition to Springfi.
C. Name, etc. of owner and construction lender
D.. Energy Sources
1. example-heat/electrical ceiling/or forced air gas
2. examDle-water heater/electrical/or solar
E. Square footage or valuation, etc. -
1. example-1250 sq. foot hause, 500 sq. foot garag
2. example-if new project, check new-if addition, d
odd, etc.
F. Building'permit information:
1. example-construct single family house with on at
garage
2. .example.remodel existing garage into family roo
J. 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 Divi
Staff must bc able to contact appropriate persons rei
design informction or job site corrections, etc.
II. Abbreviated Plumbing, Mechanical & Electrical Schedule
A. Except where blank spaces occur in the description p
of the Mechanical and Electrical Schedules, the appli
need fill.in only the No. Boxes adjacent to the appro
item(s) 10 be installed
B. Full Plumbing, Mechanical, and Electrical Schedules
ore available at the Building Division
1. To conserve space on the permit form the schedull
hove been abbreviated
2. If the item(s) to be installed ore not covered on thf
ated schedules you should consult the full schedul,
C_ BUilDING DIVISION STAFF WILL FILL OUT ALL FEES A
CHARGES ON THE SCHEDULES
III. Applicant to sign and date
Whenever possible, the initial application will be used a!
worksheet only. Where possible, Building Division Stoff,
prepare 0 typewritten copy and return it to the applicant
the time the actual permit is issued for his signature.
IV.
V. FOR OFFICE USE ONLY
I'ROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Additional Project Information:
PLANS REVIEWED BY,
. "';gnaturo.
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PERMIT V ALIDA lION
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CITY OF SPRINGFIELD
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City Hall
Springfield, Oregan
Department af Public Works
OFFICIAL RECEIPT
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( . No. B 5 6 0 6 4 (
Date~ - /l 19<6 I.
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