HomeMy WebLinkAboutPermit Backflow Test 1987-2-3
IINSPECTION LINE
1226-3769
;Ob Address ~ 2 4- \V\f11 r\ s.+
legal De5cription
.
CITY Of SPRINGfIELD
COMBIIIATION APPLICATION/PERMIT
E!lERGY SOURCES:
Heat
Hater Heater
Range
Va 1 UE of I'lor~:
.
INfORlIATIDN LINt
726-3753
Sq. ftg. I.lain
~q. Ftg. Access.
Sq. ftg. Other
New Add Alter Rep.
Fence_Demo _Change/Use
_Other
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Owner\exQ..(C) .
Address4-\l.4- (\AL\\Y\ ':::sf-.
Phone
BuilriinQ Permit Info: Describe Work{i.e., Build Single
Familv nesidence With Attached Garaoel
:\\Y\~V
lvt r k: -1\C'h) cU.\{j 0 L
Construction Lender
Address
DESIGN TEAr~
(name)
Phone
(address)
(lics. no.)
(exo;res)
(ohane no.')
Primary
Electrical
\\............
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C, Q~'7, 10Cj"'/
,
t/ -;-1
Structural
Mechanical
CONTRACTORS
(name)
(address r-
(lic~. no.)
(pxoil"'pc;,1
(ohnnp no_ 1
General
Plumbino
S+I~9'>r\ \J\\\l\\h?J \?,liG-j l J~Mt\\ I=-IIWV
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Electrical
Mechanical
PLUI.1BING
ELECTRICAL
MECHANICAL
NO.
fEf I..QjARGf Nn
~H. r~l1RG.E. NO
~~!:' r...HA.RtlE.
Each single fixture
Residence of
SQ. FT.
furnace/burner to
BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
(] bath \
Duplex (1 bath) each
SERVICES
Recessed wall
Sn~r~ np~tpr ~nrl vpnt
ITempOrary Construction
IChange in existing
rec;.jnYJlce
Imultifamily, comm. or
Induc;.triilil
IOf
ICO~~./IND. FEEDERS
I Install/alter/relocate
rlic;.tr;n_ fppnprc;.
IOf amp~1
I
I
",0] I. I I
TOTAL CHARGES \'5 ,CS-C:', TOTAL CHARGES I TOTAL CHARGES
WHERE STATE L,\l~ REQUIRES that the Electrical wor~ be done by an, Electrical Contractor, the electrical rortion of this perr.1it
shall not be valiJ until the label has been signed by an Electrical Supervisor and returned to the Building Division
b;ITrK\1 )
C\~IU
amps.
Appliance vent
<;poarilite
Stationary evap.
cooler
Vent fan wi th
sinole duct
Vent system apart from I
heatino or A.C.
Mechanical exhaust
hond ilind duct
Additional bath
~Iater service
Sewer
\tS.6t:
Wood stove/heater
ISSUANCE OF PFRI1IT
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 UO OCCUPArKY 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 compliance with ORS 701.055 will be used on this project.
Zone
Fire Zone
Flood Plain
Tvpe/Const.
Bedrooms
Stories
Units
Occy Load
Occy Group
SIGNATURE ~
fOr. OfFICE USE DIlLY
Sq. Ftg. t1ain
Sq. ft9. Access
Sq. Ftg. Other
ST',
DATE ;1./3/"7
I1Ar.IE(please print) D.. ~ <::, 1--,.... \; "" "'-
x Value
x Value
x Va 1 ue
TOTAL VALUATION
Plan C~. Comm/Ind
65%/Bldo Per Fee
------------ Plan C~. R-es
30%/BldQ Per Fee
PLU!~BING PERMIT ( J~ DO fence
Charges and -- ~......------
Surcha rges ..... r ro 0 DlllllO
ELECTRICAL PERrm I.Sidewa 1 ~
Charges and ------------
Surcharges I A/C Paving
MECHANICAL PERMIT I Curb Cut
Charges and ____________1
Surcharges
BUILDING PERmT
Charges and
Surcharges
Systems Development
Char~e (1.5~)
Total Comb. Permit
TOTALtf 15, 00
.
;.
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A. Job Address
B. legal Description
I. example- Tax lot 100, lane County Map Reference
11 03 43
2. example- lot I. Block 3, 2nd Addition to
~prlngtield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
'1. example. heat/electrical ceiling/or forced air Qas
2. examDle- waterheater/electrlcal/or solar
E. Square footage or valuation, etc. -
I. examole- 1250 sq. foot house, SOD sq. foot garage
2. example- if new project, check:n.;w - if addition,
check add, etc.
F. Building permit information:
1. exam~le - construct single family house with an
attached garage
2. example - 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. BUIlOING 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 CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
.
.
PERMIT VALIDATION
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dY~ &114-~
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Permit Cl erk
~
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
.
date
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STIMSON PLUMBmG & HEATING, INC.
1299 OCEAN STREET
EUGENE, OREGON 97402
(503) 687.1351
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BACK FLOW PREVENTION DEVICE TEST REPORT V
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, I I STREET
. 5tp IT II N J'lI .c;1 Fild 1 I , t , , I , I '-LLI , 1 I I I 1 I
01TY liP
g:':CE '" ,.1" ~~E UbGQ , I MODELtP,:<,S:Y,
~iON N f=..X T f(J y(}F -r €r ~~%~~R ,L ,3,9.10'/,
REDUCED PRESSURE DEVICE I PRESSURE VACUUM
DOUBLE CHECK VALVE CHECK # 1 BREAKER
CHECK # 1 CHECK # 2 I AIR INLET CHECK
~S J;,ROP I
llmAL 1lE~~~Il<1, E~T. OPENED AT PRESS DROP
lIST TIGHT OllGHT 0 I
. PSI! LU.UPSlO LU.UPSlll
REUEF VALVE I
lEAKED 0 lEAKED 0 _A
PASSED lll" 'I 010 NOT
FAILED 0 OPEN 0
, ,
I I I I
INITIAL TEST ;,,;-
PASSED ~
FA'LED 0
OATE~/L~>@
I
lEAKED
REPAIRS
AND/OR
PARTS i
I
I
~R I TlGHT 0
REPAIR!
"
., PRESS DRDPj'
LU.UPSCl
RELIEF OPEN
.LU.UP'SIl .
DETECTOR METER READING
IN COMPLETING AND SUBMITTING THIS TEST REPORT. THE TESTER CERTIFIES THAT THE
DEVICE HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF mE. WATER SYSTEM OWNER AND THE STATE OF OREGON,
AFTER REPAIR
OPENED AT PRESS DROP
DATE:LU/LU/LU
TlGHT 0
LLJ-U I'Sll L1-.J-UI'SII
~hU
/
f /rIJ'Uvu
TESTERS SIGNATURE
ISo
B ;). rO
CERT .
GAUGE.
BY, .
~ K
f/~ ~ r-1~ (REPRESENTATIVE OR FIRMI
I CERTIFY mE'"ABovE TEST HAS BEEN PERfORMED
WATER SYSTE;,lS COpy
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