HomeMy WebLinkAboutPermit Backflow Test 1988-2-23
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"I INSPECTION LINE
726-3769
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CITY Uf SPRINGFIElD
COMBIIIATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
Hater Heater
.
INFORltATION LlNt
726-3753
Sq. Ftg. ',Ia i n
~q. Ftg. Access.
Sq. Ftg. Other
New Add Alter Rep.
--Fence Demo Change/Use
-Other- -
Job Address tfl'-{cf-f) fYla4v
Legal OescriPtio'n / '1 0 _:1 3 ~ L( d.
<1-~ fb~IfJ.u/2~7'
Owner' ~ ~fH\)
Address gY:3 7 t..J;ei~
Construction
~
Lender
Phone '1 rLf,
ooc(7
BuilciinlJ Pennit Info: Describe Work( Leq
Fam~ nesidence Hit~ Att. aCh~d ,.raoe I
'.fI-:'A /' h.ll\r'l 'j--WI'J
t:%///'1-/r/ ~;;..-
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Build Single
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C\)
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fjU ro /
Range
ValuE. of Work:
Address
UtS IoN I EAI~
(name)
Phone
(address)
nics. no.)
(exoiresl
,
(ohone no ~
Pri ma ry
Structura 1
?
Ct...G1 , CS ~oCl
Electrical
11echanical
::::::~TORS n (na("~ _ . la;pssl,
Plumbino !//~ t1-.'::,~i: ---/VJrJ~,J
Electrical 1/
f1 ics. nIL)
(~xnirp<;'
(I)honp no
&(/0-:1001 ./
--y--F
~1echanical
PLUIIBI NG
ELECTRICAL
MECHANICAL
-1!Q.1
Each single fixture
I FFF I rl-IIl.Rr;f rm J
Residence of
1 ITLI..c.I:IARG.E. NO I
I FH" I rl-lAWi[
furnace/burner to
SQ. FT. BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
11 bath)
Duplex (1 bath) each
SERVICES
Recessed wall
~n~rp hp~tp~ Ann vpnt
?OJ
ITemporary Construction
IChange in existing
~ps. i rJp"nrp
ImultifamilY, comm. or
Tndllc:.tri~l
10f ' amps,1
ICO~~./IND, FEEDERS
IInstall/alter/relocate
dic:.trih. fpptip~c:.
IOf amp~1
I
Appliance vent
se021~~tFl
Stationary evap.
coolH
Vent fan with
sinole duct
Vent system apart from
heatinq n~ A.C.
Mechanical exhaust
hoor! <Inri tiur:t.
Additional bath
Water service
Sewer
Storm Sewer
Wood stove/heater
ISSUANCF OF PFRmT
TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES
WHERE STATE L\\~ REQUIRES that the Electrical work be done by an, Electrical Contractor, the electrical rortion of this pernit
shall not be vali1 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. an that NO OCCUPAr~CY will be made
of any structure without the permission of the Building Division. I further certify that my gistration with the Builder's
Board is in full force and effect as required by OR$ 701.055. that if exempt t y asis for mption is noted hereon, and that
only subcontractors and employees who are in compliance with ORS 7Ql.055 wi e used t project.
Zone
Fire Zone
Flood Plain
Tvpe/Const.
Bed rooms
Stories
Units
Occy Load
Occ.y Group
SIGNATUR <
FOP. OFFICE USE ONLY
Sq. Ftg. rlain
Sq. Ft~. Access
Sq. Ftg. Other
.1%-'
DATE ~ -..2-
HAME(please print)
Cb~IL
SAyot\J
x Value
x Va 1 ue
x Value
TOTAL V ALUA TI ON
PLUMBING PERMIT
Charges and
SurCharges
5
Plan Ck. Comm/lnd
65%/Rldo Ppr Fpp
------------PTan Ck. lies '
30%/Bldo Per Fee
'"3 (), 00 Fence
--n__n,-:&'J-I O~mo
I'Sidewalk
I AIC Paving
I Curb Cut
I
syste. r.lS Development I
Charoe (I.5~)
BUILDING PERfIlT
Charges and
Surcharges
ELECTRICAL PERr~lT
Charges and
Surcharges
I
I
MECHANICAL PERMIT
Charges and
Surcharges
ITotal Comb. Permit
I TOTAL I 3/.&0
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COMBINATION APPLICATION/PERMIT (CAP)
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
Sprlngtield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. examyle- heat/electrical ceilinq/or forced air Qas
2. examole- 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:ruew - if addition,
check add, etc.
F. Building pennit information:
1. examole - construct single family house with an
attached garoge
2. examole - remodel existing garage into family room
3. examole. 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 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
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. ---
Ill, 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
signa ture.
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:
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PERMIT VALIDATION
/0 if 3;;L
:J-:J-3-! t
Permit Clerk
c~
.
.
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
,
date