HomeMy WebLinkAboutPermit Backflow Test 1988-7-19
I INSPECTION LINE
726-3769
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Legal Description L7 ^ '7
Job Address
.
.
JNFOR/1ATION lINl
726-3753
Sq, Ftg, 1.lain
~q, Ftg, Access,
Sq, Ftg. Other
Ilew Add A Her Pep.
-Fence Demo Change/Use
-Other- -
CITY UF SPRINGFIELD
COMBIIIATION APPLICATION/PERMIT
EIIERGY SOURCES:
Heat
Hater Heater
Range
ValuE of Work:
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Address
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Owner
Construction lender
Address
UlSlull TlA'"
(name)
Primary
Structura 1
Electrical
Mechanical
CONTRACTORS
(name)
Genera 1
Plumbino ~)J. lJ\ni
Electrical ()
~1echanical
PLUI,IBI NG
110.
Each single fixture
Relocated building
(new fix, additional)
S.F. Residence
11 bath)
Duplex (1 bath) each
Additional bath
~Iater service
Sewer
Storm Sewer
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TOTAL CHARGES
WHERE STATE LAW REQUIRES
shall not be valiJ until the
BuildinQ Permit Info: Describe Work(;~e" Build Single
Family nesidence With Attached Garaoe)
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Phone
{address 1
(1 ics. no.)
(exniresl
(ohone no.)
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s-:'j c..C
/),-y'\
(address)
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Q.6-IQS-PB 171.3t!'i'>"6
1 'II -0202'/ =<.
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ELECTRICAL
MECHAN I CAL
FEE CHARGE Nn~
Residence of
SQ, FT.
New circuits alts.
or extensions
SERVICES
Temporary Construction
Change in existing
rp~j4en~r
multifamily, COntn. or
Tndustrial
Of amps.
15a: COMH,/IND, FEEDERS
Install/alter/relocate
dic;trih. fppdprc;
Of amps.
FFF rH~ Nn,
FFF rlJARliE.
furnace/burner to
BTU's
Floor furnace
and vent
Recessed wall
Sn~~p hp~tpr ~nd vpnt
App 1; ance vent
~po~ratp
Stationary evap.
coolar
Vent fan with
sinole duct
Vent system apart from
heatina or A.C.
MeChanical exhaust
hood and duc-t
Wood stove/heater
16 c9- TOTAL CHARGES
that the Electrical work be done by an'
label has been signed by an Electrical
JSSUAIICF nF PfRI11T
TOTAL CHARGES
Electrical Contractor, the electrical portion of this permit
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 rw 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 701.055 will be used on this project.
rW'lE(p1ease print) -;J;,hvJ k,.;c Id SIGIlATURE /;hLO _W OATE ?-/1-&fS'
FOP. OFFICE USE O~LY
Zone Tvpe/Const. Units. Sq. Ftg, Ilain x Value
Fire Zone Bedrooms Occy Load Sq. Ft!J. Access x Value
Flood Plain Stories Occy Group Sq, Ftg. Other x Value
Plan Ck, Comm/Ind
____________ ....Q.2!/Blda Pj'r Fpp
Plan Ck, Res
30%/Bldo Per Fee
~'___j~,~__ Fence
,~5 DfiIIlO
BUILDING PER/lIT
Charges and
Surcharges
PLU'1B ING PERfoII T('
Charges and /~. .
Surcharges'
TOTAL VALUATIOIl
Systems Development
Charqe (1.5~) ,
ELECTRICAL PERIHT 'Sldewa 1 k
Charges and ------------
Surcharges A/e Paving
MECHANICAL PERMIT
Charges and
Surcharges
Total Comb. Permit
Curb Cut
1'5 12-
TOTAL
.
.
COMBINATION APPLICATION/PERMIT (CAP)
I. Applicant to furnish
A, Job Address
B. legal Description
I, example- Tax lot 100, lane County Map Reference
17 03 43
2, example- lot I, Block 3, 2nd Addition to
Sprlngfield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. example. heat/electrical ceilinq/or forced air Qas
2. example- waterheater/electrlcal/or solar
E, Square footage or valuation, etc. -
I, example- 1250 sq, foot house, 500 sq, foot garage
2. examp.le- if new project. check:new - if addition,
check: add, etc.
F. Building pennit information:
1. example - construct single family house with an
attached garage
2. examEle - remodel existing garage into family room
3, example - 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 TEAN AND CONTRACTORS
To avoid design or construction delays. Building
Division Staff must be able to contact appropriate
persons regarding design information or jab 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 schedul es
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 CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
.
.
!
PERMIT VALIDATION
'?EZ!.c7 f'7r
Permit Cl erk
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Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
.. . .."
PLANS REVIEWED BY:
name
signature
date
'.,