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HomeMy WebLinkAboutPermit Backflow Test 1983-5-5 /11 INSPECTION LINE. ,) 'l 726-3769 / --L ~()~f)tod ) .j, CfiY/-j-,()[': 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 (\ . UNt C'-- 'e./) ~ -... {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 . .......,.,~ '_..'. .;.,.......,..'..', . .,'".",.;;.--..........._...,'""...,A...c;":."...,.,."~.'"'..._"'... j J date