HomeMy WebLinkAboutPermit Backflow Test 1987-11-9
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BACKFLOW PREVENTION DEVICE TEST REI'Offr
FIRM
NAME:
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DEVICE
ADDRESS:
DEVICE "7 OEVICE 'T/' 0- " 0
SIZE: L!.V lC); , MAKE: UIA'I if ,S, I I MOOELI./' VJ ./, , ,
~g~~ON..:5A~ ('/k"/lJ....... ,-;ffi.."';:J<!..~~~RI/ r3,'-,.;t,Oi-S', , , '-LJ
" REDUCED PRESSUHE DEV'CE PRESSURE VACUUM
I DOUBLE CHECK VALVE I CHECK' 1 : BREAKER
I CHECK' 1 I CHECK' 2 I I AIR iNLET CHECK
PR~S DROP
INlnAl !lICiHT 0 TIGHT 0 IR~~;'~r OPENED AT PRESS DROP
TEST I LgI,J.;:r "" L1.J.U... l.U'U",
RELIEF VALVE
LEAKED 0 LEAKED 0
PASSED 0 OlD NOT LEAKED
I 7 t FAILED 0 OPEN 0
- (Rrf'!f}; IE /1 W tE I~I
REPAIRS ul,'
AND/OR ...:::,..
PAIlIS I NO
I V 9 1987 II
: k ,"F111'5:jOtlOP I I II AmRREPA'R
TEST ! tAl Ii It: CN ~~ J.L!PSlIJ OPENED J\T pn[ss DROP II .)e;p: I I I'l J J/L-LJ
AFTER r[Jffl ~ I TlcJw -V- I:' ~ --~ - .-
REPAIR I I REUE~ OP!:.;'1' , I'
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INITIAL TE~
PASSED t::I
FAILED 0
DATE i.J!..J/I'1...JI!J:.l
~
DETECTOR MEEP.F.F.AOING __
IN corv1p!...ETING AND SUBMlrnNGIHI$ .fEST HEPonr, IHE ,ESTER CERf1H!::S THAT THE
DEVICl:: HAS Sr:EN TES"!ED AND MAINT/'dNED iN ACCOHUf\J.jCE WITH l\Lt APPLlCABl.E
RULE~ AND REGUl.AlIONS OF lHE '1\~lER SY~;TE!\'l OWNER ANO THE ST/\TE Cf onH;O,~.
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J0..._J@ ~~~
TEST!:!1S SIGNATURE
BY: oJ- f V -' (REPRESENTATlVE OH FIRM)
~Sy THE ABOVE TEST HAS BEEN PERFORMED
WATER S\'STa,s COP\'
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GAUGE II
.1.4 / 9"9
CEHT,
I INSPECTION LINE
726-3769
.
Job Address
lfI~,;25 /J1~
Omription /70;) 3.;1. .3 /
o ~ 3of)
CITY Uf SPRINGFIELD
COMBINATION APPLICATION/PERMIT
E!lERGY SOURCES:
Heat
Hater Heater
Range
ValuE of Hork:
.
INFORlIATlON liNe
726-3753
Sq. Ftq. 1.lain
~q. Ftg. Access.
Sq. Ftg. Other
New Add Alter Rep.
-Fence Demo Change/Use
Other- -
c:x::)
~
Legal
N~ r/1WC
tfc{:zs ~
f0.reuJ POA if, ,,-ftJ-U_
Construction lerl6er
Address
~'/I-
Phone d 555
Owner
rA
~/),/"
BuilriinQ Permit Info: Describe Work(;.e.. Build Single
Familv nesidence With Attached GaraQe)
~/14izLUhh-. ~ 1/}
6u/u lrTK-1 n/z/ z,. .P./
I
~
~
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Address
DeS IoN I eAI1
(name)
Phone
(address)
(1 ics. no.)
(exn; res)
(nhone no.')
Primary
Structural
Electrical
0~"
S~OU
Mechanical
CONTRACTORS
(name)
(address)
(1 ie's. nn.)
(pxoires)
(Oho",," no.)
Plumbino
JMcut
,/
/
~rI
,
Genera 1
_ .71.1
r,
E1 ectri ca 1
~'echanical
PLUI,!B I NG
ELECTRICAL
MECHANICAL
NO.
Each single fixture
FEE [HARf,F .n <<< rlJARli[ ...Ill)....!
Residence of furnace/burner to
SQ. FT. BTU's
ccc rl:fARG..E..
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
(1 bathl
Duplex (1 bath) each
Additional bath
SERVICES
Recessed wall
~O~CP hp~tpr ~nr! vpnt
Storm Sewer
Of
amps.
Appliance vent
seoari\tp
Stationary evap.
cooler
Vent fa'n with
sinolp dLJct
Vent system apart from
heatinq or A.C.
Mechanical exhaust
hood and duct
Wood stove/heater
Sewer
Temporary Construction
Change in existing
rpc:.i1t;::nrp
mul ti fami ly. COnTn. or
TnrllJc:.tri~l
~Iater service
CDMM./IND. FEEDERS
Install/alter/relocate
r!idrih fpprlprc:.
i'\
Of
amps.
,~ ~
fV'~ \0\1;
ISSUANCE OF PFRI1lT
TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES
WHERE STATE L.\I/ REQUIRES that the Electrical work be done by an.'Electrical Contractor, the electrical portion of this permit
shall not be vali~ 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 performed shall be done in accordance with the Ordinances of the City
of Spri n9 fi e ld and the Laws of the State of Oregon perta i ni ng to the work descri bed herei n 1 and tha t NO OCCUPAIKY 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 comoliance with OR5 701.055 W,ill be uped on this project.
IWIE(please print) ALL u...ec.f'( SIGNATURE 0) ~/ - ~ATE/2~.:2 (-t~:
FOR OFF I CE USE DIlLY
Sq. Ftg.
Sq. Ftg.
Sq. Ftg.
Zone
Tvpe/Const.
Bedrooms
Units
Occy Load
Occy Group
riain
Access
Other
,x
Value
Value
Value
Fi re Zone
Flood Plain
x
Stories
x
TOTAL V ALUA TI ON
PLur~BING PERMIT
Charges and
Surcharges
s
Plan Ck. Comm/lnd
____________ 65%/Bld(l Pprl='op
Plan Ck. Res
30t/Bldo Per Fee
Is, 01) I Fence
-n----~7~s_-1 Demo
I'Sidewalk
I A/C Paving
I Curb Cut
I
Systems Development
Charqe (1.5~) ,
BUILDING PERMIT
. Charges and
Surcharges
ELECTRICAL PERr:IT
Cha rges and
Surcharges
Total Comb. Permit
MECHANICAL PERMIT
Charges and
Surcharges
I
I TOTAL
fS7S-
.
.
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
II oj 43
2. example- Lot 1. Block 3, 2nd Addition to
Springfield Estates
C. Name. etc. of owner and construction lender
O. Energy Sources
1. example- heat/electrical ceilinqjor forced air oas
2. exa~le- waterheater/electrlcal/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 pennit information:
1. example - construct single family house with an
attached garage
2. example - remodel existing garage into family room
3. examyle - 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 TEM1 AND 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, 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 form the schedules
have been abbreviated
2. If the item(s) to be installed are not covered on
the abbreviated schedules you should consult the
fu 11 schedu 1 es
C. BUILDING OIVISION 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 b~ 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.
/61/'J
) ?~ :J { -- f 1
V. FOR OFFICE USE ONLY
Permit Cl erk
/(~
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
date