HomeMy WebLinkAboutPermit Backflow Test 1987-7-2
4IIIt CITY Uf SPRINGFIElD
cormIIIATION APPliCATION/PERMIT
E!IERGY SOURCES:
Heat
Hater Heater
Ranqe
Owner ItA ^. - {I/I/;jj/-Llfl.,
Address '()Y\.-/.~~Jn ~~ /}zc(/:ne, ~~~~li~n~e~~~~~eInf~h ~.~i~~h~~eG~~~~~l..e.. Build Single
I ~~ ~ db &cAc/iJ4U/Y"
1t.J/o-jf!2.() jkl J.p~-~/f7--LJ
Phon~1ztJ /Lj'~1
(addrP,5S)
jllISPECTION lllIE
726-3769
Job Address
,-=; 1 IS
rn aiM. )
legal Description
Construction Lender
Address
DESIGN TEAf1
[name)
Primat:'y
Structural
Electrical
l1echanical
CDNTRACTORS Iname)
General p,/ Pi,
Plumbina
.
INFDRflATIDN liNt
726-3753
Sq. Ftg. f.lain
~C1. Ftg. Access.
Sq. Ftg. Other
flew Add Alter Rep.
--Fence Demo Change/Use
-Other- -
oQ
......:::>
~
10
~
ValUE of Hork:
?, JI12VL
(l i~s. no.)
.3PA1./~
(exoires)
(ohane no.')
/)
//A ~ "Of I.;"";t;~r;" ~ jllirS
- I . r
Electrical
~1echan; ca 1
PlUflB I NG
ND.I FEE r.HARr,F Nn
lEach single fixture
IRelocated building
(new fix. additional)
Is,F. Residence
(1 bath)
IDuplex (1 bath) each
[Additional bath
~Iater servi ce
Sewer
Storm Sewer
-:9 Y~fl~ 1.5: 7.1 AA-
~ I . \..fl..uu.A.-/ 3V,W/SO
/Lf~1 tulaju 3D.'"ISlJ
- J
TOTAl CHARGES
WHERE STATE l~W REQUIRES
shall not be valii until the
1"10.'
(p'1(nirpc:. ,
(ohone no.)
,q~'1: ~~oO
ElECTRICAl
MECHANICAl
..,
fI--lARr.:F ~IO.
fI-lARf.:F
...
Residence of
furnace/burner to
BTU' 5
SQ. FT.
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
C;l1ilrp I-lpiltpr "ftr! \/P....t
ITempOrary Construction
I'Change in existing
rpc;.jtjp.:nrp
Imultifamily. COITlTl. or
lnr!tJc;.trial
IOf amps.
ICor1fl./lND. FEEDERS
I Install/alter/relocate
r!id.rih_ fppnprc;.
IOf amps.
I
I
I
Appl iance vent
<;.PDaratp
Stationary evap.
r.ooler
Vent fan with
c;inolp nlJr"t
Vent system apart from
heatina or A.C.
Mechanical exhaust
hoor! and r!lJr.t
Wood stove/heater
I SSUANCF OF PFR!IIT
TOTAL CHARGES
TOTAL CHARGES
that tile 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 EXAMINED the completed aprlication 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 /10 OCCUPAIlCY 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 OP.S 7Ql.055 will be used on this project. '
~\'('lA M:)(M"' SIGrlATURE Q~?I~)
\ FOR OFFICE USE Dili( /1
Units Sq. Ftg. riain
Occy Load Sq. Ftg. Access
Occy Group Sq. Ftg. Other
IWIE(please print)
Zone
Type/Const.
Bedrooms
Fi re Zone
Flood Plain
Stories
BUIlDING PER/lIT
Charges anc
Surcharges
PLU!1B ING PERMIT
Cha r..ges and S
Surcharges
_n___9fl~_
1so
ElECTRICAL PERI~IT
Cha rges and
Surcharges
11ECHANICAl PERMIT
Charges and
Surcharges
om:] .) -Rf}_
x
Value
Value
Value
x
x
TOTAl VAlUATION
Plan Ck. Comm/lnd
65%/Bldo PPf Fpe
Plan Ck. Res
30%lBldo Per Fee
Fence
Isyste.ms Development
Charoe (!.5~)
I
I
I
I
Demo
I Sidewalk
I A/C Paving
I Curb Cut
I
Total Comb. Permit
I TOTAl
I q~.S()
/J
r
"
.
.
COMBINATION APPlICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Applicant to furnish
A. Job Address
B. legal Description
1. example- Tax Lot 100. Lane County Map Reference
II U3 43
2. example- lot I. Block 3, 2nd Addition to
Sprlngtield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. exam~le- heat/electrical ceiling/or 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. exam~le. if new project. check-new - if addition,
check add. etc.
F. Building permit information:
1. examole - 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 (al of the
Structural Specialty Code
H. DESIGN TEM4 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 ~ivision 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.
(J ~ 549
-J fo 1
1/;L--B
V. FOR OFFICE USE ONlY
Permit Cl erk
~
~
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
date
l