HomeMy WebLinkAboutPermit Backflow Test 1983-5-5
/11 INSPECTION LINE. ,)
'l 726-3769 /
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1 CITY OF SPRINGFIELD
Cf'MBIIIATIOfl APPUCATIOfl/PERMIT
,,_. _" n R f'I ""/ --V ~ SOURCES:
Job Address r y~ (l,l - 'l~ 1,1), '!'- \~ /ct,,p J Heat _____ __.--
I.egal Descriptio~'~ \ \ , l;<\\\ ~ ~fi {) \J ~ l'later Heater ------
L0\i1 r.(\o Q Q:' \(,\'U,~QQ "S~:(\C'~. '~~::O~\oIork:
Owner '1)~ me )1{..LLu) j 1. IJ1YO .
Address ....c/Ol,/' OJ/~_^ ),,~...n. Phone'" Bu,l",no pernnt Info: Describe'Work(Le., Build Sing""
-'" .." /IT"" u ._~.~ ~y) fi7 Familv nesidence Ijith ~.ttached Garaoe)
- 6 ~
Eu.c~, 1YIL-,,\o1rv-=---' rJL~4 Hl~ '7vu..kv;,u,) d!u~
Construction lend~ (J (\
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{name)
Phone
(address)
(l ics. no.)
(exn; res)
r!l
1\:>0
,I
no. }
Address
DcS llirl I cAI1
(ohone
. Primary
Plumbina
(name)
rO ~~Q." GO" 'Y'IV
{address} (1;r:~. no.'
~'6qol ~. __,IJ~v&P <<If
(j"1~
~
,~
(pxnirps) (ohone no. 1
Structural
Electrical
Mechanical
CONTRACTORS
General
7'-(fo-IDIZ
E1 ectri ca 1
~1echanical
PlUllBING ElECTRI CAl
NO, . FEE . CHARGE Nn
Each single f~~ ' Residence of
J 4-r1 ~;t}~...,-: 1 < .nO SQ, FT.
Reloca d building New circuits alts.
(new fix. additional) or extensions
S,F. Residence SERVICES
(] bath)
Duplex (1 bath) each
Additional bath Temporary Construction
Water service Change in existing
r~s_i dcnce
Sewer multifamily, COIl1!1. or
Inrlustrial
Storm Sewer Of amps.
'{.to ''2.0 COMl-I. /I NO. FEEDERS
Install/alter/relocate
rlidrih. fppdpr<;
Of amps.
MECHANICAL
~~~ . r~~ _Nn
. ~~~ . r~'iRG.E..
furnace/burner to
BTU's
Floor furnace
and vent
Recessed wall
Snace heater and vent
Appliance vent
seoaratp
Stationary evap.
cooler
Vent fan with
sinole duct
Vent system apart from
heatina or A.C.
Mechanical exhaust
hood i'l:nd duct
Wood stove/heater
ISSUANCE OF PFRlllT
TOTAL CHARGES ~ 5. z 0 TOTAL CHARGES TOTAL CHARGES
. WHERE STATE L"~ REQUIRES that the Electrical work be done by an"Electrical Contractor, the electrical portion of this pernit
shall not be va1i~ until the label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXAMINED 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 UO OCCUPArKY 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 ORS 701.055, that if exempt the basis for exemption is noted hereon, and that
only subcontractors and employees who are in compliance with ORS 7Ql.055 will be used on this project.
NAf.lE(please print) LA I?/r' r JI1 lie. tJ LL U~SIGrlATUR~,"
FOR OFFICE USE OIll Y
Zone Tyoe/Const. Units Sq, Ftg. t1ain
Fire Zone Bedrooms Occy load Sq, Ft9. Access
Flood Plain Stories Occy Group Sq, Ftg. Other
b~/_C'~~ DATE5'/~/l?~
x
x
Value
Value
Value
x
TOTAL V AlUA TI ON
BUilDING PERfllT
Charges anc
Surcharges
Plan Ck, Comm/lnd
65%/Blda Ppr Fpp
------------Pian Ck. Res
30t/Bldo Per Fee
- 0 Fence
__nn'tLQ___
.:;L.O 0!lR10
'Sidewalk
Systems Development
Charoe O.5~)
PLUl1BING PERMIT
Charges and
Surcharges
ELECTRIC~,L PERI:IT
Charges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges ..
AIC Paving
Total Comb. Permit
-1
Curb Cut
TOTAL
6. 'Zo
~\
.
"
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job Address
B. legal Description
1. example- Tax lot 100, Lane County Map Reference
17 oj 43
2, example- Lot 1. Block 3. 2nd Addition to
Springtield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. example- heat/electrical ceiling/or forced air QdS
2. examoJe-'waterheater/electrical/or solar
E. Square footage or valuation, etc. ------
1. example- 1250 sq. foot house. 500 sq. foot garage
2. example- if new project. check new - if addition,
check add. etc.
F. Building pennit information:
1. example - construct single family house with an
attached garoge
2. example ~ remodel existing garage into family raom
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 TEM~ ANO CONTRACTORS
To avoid design or construction delays, Building
~ivision Staff must be able to contact appropriate
persons regarding design infonmation 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 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 fonm the schedules
have been abbreviated
2. If 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. Jhe 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.
V. FOR OFFICE USE ONLY
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
.
.
PERMIT VALIDATION
Permit clerkl:iUY'liO ./6..,
ICYlY
.
'Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
,
PLANS REVIEWED BY:
name
signature
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date