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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 '\'. .......:--. ....... ,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 .