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HomeMy WebLinkAboutPermit Backflow Test 1987-11-9 ~ -.s;:r;~ . Jo~ y tr'. .~~ .. 5~O *~~ ,.:p /VeLC) BACKFLOW PREVENTION DEVICE TEST REI'Offr FIRM NAME: Ir..h,e,~ ,,'~ f,;j~LL.1 , , '-LLL.LLLl...L!..-L.J ,1';'7';':&.0, VJ1,4~'[~5/"-' ")l' I '_LLL.L.l..L.-L..i,...LLL.L.J smEC!' I~.oll-"'I IIt-j J! ~l/lcr l't;...L"(?'{t....,Li 19,7, Y, ;;'.fi I I , ! I I , 'c:ry <:IP 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' I LJ..J-Lj 1"'-'.1 !__LJ.L'l"-'>) ~ I LJ_J6Lfr'~ k II '--1 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,~. ;"/' 1-'./ Q . ;I?':'~" J0..._J@ ~~~ TEST!:!1S SIGNATURE BY: oJ- f V -' (REPRESENTATlVE OH FIRM) ~Sy THE ABOVE TEST HAS BEEN PERFORMED WATER S\'STa,s COP\' /f7&' 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 ~ ~ ~ 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