HomeMy WebLinkAboutPermit Backflow Test 1987-10-14
JINSPECTION LINE
726-3769
Job Address ~~ ~~
legal Description
.
CITY OF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
E!IERGY SOURCES:
Heat
\~ater Heater
Range
Valu€ of Hark:
.
I NF0R11A TI ON Ll Nt "
726-3753
Sq. Ftg. I'!ain
~q. Ftg. Access.
Sq. Ft9, Other
New Add Alter Pep.
--Fence Demo Change/Use
Other - -
X)
-:::::.
10
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.......:--.
.......
,rIl~
Owner
lted6
(jh{~ tl-TlAP,
J?'7 a..L-,.. ) Phon.r; </ (...,
td..hs
Address
Ut~Jl:iN ll:AH
(naJ:le1
Phone
(address)
BuilriinQ Permit Info: Describe Work(i.e., Build Single
Family Residence With Attached Garaae}
~~H~
rc/tu-xJ f'Jr&#~~()_
I'
I~
Address ~/r"l 9,::::;
Construction Lender
nics. no.l
(exoires)
(l)l,one no.- I
Primary
Structural
~ ..,&:1
--, -:5- I
(,41(
,
-GUI::(
Electrical
Mechanical
CONTRACTORS
I MIle I
(address)
(lies. no.'
(~xf)irp,,'
(ohonp no
Genera 1
iJAfM)
#
~f
~
PlumbinCl
~
, Electrical
~'echan;cal
PlIIroIllIG
ELECTRICAL
MECHANICAL
NO. I
Each single fixture
, FfF ; f}U~Qr;F till....-'
Residence of
crt' _'__t.:~;RGI NO
I t't"t' _' ~u11R.G..E
SQ. FT,
furnace/burner to
BTU's
Relocated building
(new fix. ad~itional)
S.F. Residence
(] batlll
Duplex (I bath) each
Additi....l bath
New circuits alts.
or extensions
Floor furnace
and vent
ISERVICES
I
Recessed wall
So~r.P hPntpr ~nrl vpnt
~Iater service
I
I
I
I I
1 I
J1 I
l' I
I I
I 1
ITemporary Construction
IChange in existing
rp~ j r1J".nr-p
Imultifamily, camm. or
Indus-trial
Sewer
I Storm Sea'er
Of
COMM./IND. FEEDERS
1 Install/alter/relocate
dic;trih. fpp(II'rc;.
IOf amp~1
I
1
I
amps.
Appliance vent
c;poar"l.te
Stationary evap.
cooler
Vent fan wi th
sinole duct
Vent system apart from 1
heatinq or A.C.
1 Mechanical exhaust
hood and duct.
I ~'Jood stove/heater
I
TOTAL CHARGES
WHERE STATE L~ REQUIRES
sha 11 not be vaJi.J until the
TOTAL CHARGES
ISSUANCE OF PFRmT
TOTAt CHARGES
that the Electrical work be done by an.'Electrical Contractor, the electrical portion of this permit
label has been signed by an Electrical Supervisor and returned to the BUilding Division
I HAVE CAREfullY EXArUNED the completed apfllication 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 rm OCCUPAHCY will be made
of any structure ~thout 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 701.055 will be used on this project.
NAI.IE(please PrinttjJ~lS
P Lit M ;"i//q_SIGIIATURE ar ;( tZw~
~ rFOP. OFFICE USE OfILY /
DATE /$)-/ t./
/
I
Zone Tyoe/Const. Units Sq. Ftg. riain x Value
Fire Zone Bed roOlBS Occy Load Sq. Ftg. Access x Value
Flood Plain Stories Occy Group Sq. Ftg. Other x Value
TOTAL V ALUA TI ON
BUILDING PER~1lT Pl an Ck. Conm/lnd S~stems Development
Charges and ----------- 65%/Bldn Ppr Fpe C arqe (I. 5%) .
Surcharges Plan Ck. Res
30%lBldo Per Fee
PLUt~BING PERMIT _n_J.s-,~~__ Fence I
Charges and
Surcha rges c; .75 Demo I
ELECTRICAL PERt~IT I'Sidewalk I
Charges and ------------
Surcharges I A/C Pay! n9 ITotal Comb. Permit
/lECHANICAL PERMIT I Cu'rb Cut 1-
Charges and ------------
Surcharges I I'OTAL
(5,75
.
.
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Applicant to furnish
A. Job Address
B. Legal Description
I. example- Tax Lot 100, Lane County Map Reference
II U3 43 .
2. example- Lot I. Block 3, 2nd Addition to
~prlngtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. exam~le- heat/electrical ceilin~/or forced air Qas
2. exa~le- waterheater/electrlcal/or solar
E. Square footage or valuation. etc.
I. 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. exam~le - construct single family house with a~
attached garage
2. exam~le - remodel existing garage into family foam
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 TEAM AND CONTRACTORS
To avoid design or construction delays. Building
Division 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 penmit 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. The 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 penmit is issued.
If) 3 ~.L~ 1
( 0 <' (L-f
V. FOR OFFICE USE ONLY
Permit Clerk ~
.
l
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Bui'lder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
date
.