HomeMy WebLinkAboutPermit Backflow Test 1988-2-10
jINSPECTION LINE
726-3769
Job Address I{\~ HQ..~
Legal Oescription 17 ()~ 301 .3 ~
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CITY UF SPRINGFIELD
COMBINATION APPLICATION/PERMIT
E!lERGY SOURCES:
Heat
\~ater Heater
Range
ValuE of Work:
.
INFORlIATlON UNl
726-3753
Sq. Ftq. '.la;o
~q. Ftg. Access.
Sq. Ftg, Other
New Add Alter Pep.
-Fence Oemo Change/Use
Other- -
~
D
Owner-
HWj!\ ~\-ve?- Au.h~
wai1Vll 1VI(\ I V"\
~nl. -"......
Phone '1~,
Buildlna Permit Info: Describe Work(i.e., Build Single
Familv Residence With Attached Garaae)
-:;h.~~.DW UeJ l c.G'
o
Address
Construction Lender
A.ddress
Ul>IGN IlAr~ (name)
Primary .
Structural ~
Electrical
Mechanical Ft-
CONTRACTORS (name)
Genera 1
Plumbina Au~hll1 HIJ..\'I.\..'oiW,\
Electrical
Mechanical
Phone
(address)
flies. no.l
{exoiresl
(ohane no.
h
"'I)
C1~,,)
,_ , r1[)
,'? I
(address)
(l ;1"0:;:. no.)
(pxoirpc;:\
(ohnnp on ,
p,/),\3. l72.q
f::.U9~'17'f'1O
~o -I
1..:>/ 'g"fl
2H.3 - 57<1 y-
PLUI.lBING
ELECTRICAL
MECHANICAL
....!JQ."
FEE CHARGF NO
J:'J:'r rlfARG.E. NO
H r r'MR!iE..
Each single fixture
Residence of
SQ. fT.
furnace/burner to
BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor fu rnace
and vent
S.F. Residence
(] bath)
Ouplex (1 bath) each
Additional bath
SERVICES
Recessed wall
Sn~~~ hp~tpr ~nrl vpnt
Storm Sewer
'Rtl-rK..~ J:bJ. 15d:
Of
amps.
Appliance vent
c;,~aariltp
Stationary evap.
cooler
Vent fan with
~inole duct
Vent system apart from
heatino or A.C.
Mechanical exhaust
hood and du('t
~Iater service
Temporary Construction
Change in existing
fp<;jcje.ncp
multifamily, corrm. or
lnrlll"trial
Sewer
CO~1./IND. FEEOERS
Install/alter/relocate
rtic:tritL fpprll'rc:
Wood stove/heater
Of
amps.
')0]
ISSUANCf OF PFRllIT
TOTAL CHARGES
WHERE STATE LAW REQUIRES
shall not be vali1 until the
TOTAL CHARGES
TOTAL CHARGES
that the Electrical work be done by an.'Electrical Contractor, the electrical portion of this pemit
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, and that 110 OCCUPAllCY will be made
of any structure without the permission of the Building Division. I further certify that my registration with the Builder1s
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 7nl.055. will be used on this project.
IlAI-lE(please print) ~ f' y l\~l\V~ ~ C... ~ 'C,v l.. (,Y'\
SIGNATUREB,~\ ~ J. ~
OATE 1..1 \0\ \'\
Zone
Fi re Zone
flood Plain
Tyoe/Const.
Bedrooms
Stories
Units
Occy Load
Occy Group
FO~ OFFICE USE DIlLY
Sq. Ftg. r1ain
Sq. Ftg. Access
Sq. Ftg. Other
x
Value
Value
Value
x
x
TOTAL VALUATION
BUlLOING PER~1lT
Charges and
Surcharges
Plan Ck. Comm/lod
65%/Rlda Ppr Fpp
'-----------"'P'ian Ck. R'es
30%/Blda Per Fee
,______Lti.9.Q Fence
,'75 O~o
'Sidewa 1 k
Syste~s Development
Charae (1.5~) .
PLUl1BING PERMIT
Charges and /'
Surcharges ~
ELECTRICAL PERIIlT
Charges and
Surcharges
MECHANICAL PERMIT
Charges and
Surcharges
A/C Paving
___________J Curb Cut
I
Total Comb. Permit
I TOTAL
/512
.--
'.
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A, Job Address
B. Legal Description
I. example- Tax Lot 100, Lane County Map Reference
II oj 43
2. example- Lot I. Block 3, 2nd Addition to
SprIngfield Estates
C. Name. etc. of owner and construction lender
O. Energy Sources
1. examyle- heat/electrical ceilinqjor forced air Qas
2. example- waterheater/electrlcal/or solar
E. Square footage or valuation, etc.
I. examole- 1250 sq. foot house, 500 sq. foot garage
2. example- if new project, check-new - if addition,
check. add, etc.
F. Building permit information:
1. examele - construct single family house with an
attached garage
2. exam~le - remodel existing garage into family room
3. exam~le - 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. ---
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 permit is issued.
V. FOR OFFICE USE ONLY
PROJECT CONOITIONS TO BE SATISFIED BEFORE OCCUPANCY:
,
PERMIT VALIDATION
~.
C2 -/0 - ~
/6qa2~
Permit Clerk
\ '
if- - Ch(~
d)/L
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Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
,
date