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Home My WebLink AboutPermit Backflow Test 1986-6-12 ---'.--... -~"'-'-"',''''-, . " ~""- .' ..# .... .........;.-_.-... - ...... ... ." ..__...._..u.._.......__ _.._._~ CITY Uf SPRIN"FYE~O COMBINATION APPLICATION/PERMIT EIIERGY SOURCES: Heat Water Heater . Ranqe " '_'- I .. h . I ::7.' --1. .. . . /.. Valu€ of Hork: Owner U/Ce.M UI/!>>Jn fUl..C.- U417A-15/#(5;51lJ/} WI- :: , . Addre.. t1//Jne::- I.; '7 H Phon.211Ii.. . BUildino P~nnit Info: Describe Work(;..e., Build Single crD~UJ -r: r':;;r ~~"~:;ltW Construction [ender ;?-11'/~ .~~~ 1-1-- I , , , I '.Install/alter/relocate I' I rli~trih_ f~~rl~rc 10f amp~1 I I 1.(,1{) I , I I' i I " I I ISSUANCE OF PFR/lIT 15.&.0 TOTAL CHARGES .1 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 OCCUPANCY 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 ORS 701.055, that if exempt the basis for exemption is noted hereon, and that only ~ubcontractors and employees who are in compliance With.ORS 701.055 will ~ used on this ~r:7"ct. fW1E(please print) )C~,4~-'f HtfSL.,/, SIGIIATURE)( L uJ ~ DATE b-l:J..-(jb FO~ 9FFICE USE OIIL Y 1/ y Sq. Ftg. f1ain x Sq. Ftg. Access x Sq. Ftg. Other x ,.~ iINSPECTION LINE i 726-3769 Job Address ~qqo mtl~ ,- Legal Description Address Ut.;)lliN TEAr" ~' Primary Structural Phone (addrl'!ssl (name) flks.no.l Electrical Mechanical CONTRACTORS (namel (addrpssl . (lir.e;;. nn.l General ,t' ,_,1,1 I)' . I. J ''Z Plumbin. I'1a:'IJf!51J>I~u/6t..U k:f(dtT-w~1 <<bA'J1bU..(> Electrical I ~ {I '-...J ml~!"n S.F. Residence 11 bath \ Duplex (1 bath) each IAdditional bath -----'water service I Sewer IStorm Sewe~ I~~ I /. I I .t/% I I SERVICES ITemporary Construction ~Change in existing I r~sjrlJ'nl"'~ 'multifamily. comm. or Inrllldri"l Of amps~ /5. 00 COHfl./IND. FEEDERS TOTAL CHARGES WHERE STATE L'W REQUIRES shall not be valid until the ., Zone Fi re Zone Tvpe/Const. Bedrooms Units Occy Load Occy Group Flood Plain Stories BUILDING PWlIT Charges and Surcharges Plan Ck. C_/Ind 65%/Bldn P~r f~p Plan Ck. Res JOS/Bld. Per Fee __n_L~_/::!_ Fence ; too Detna 'Sidewalk ------------ I A/C Paving ____________1 Curb Cut' , PLUMBING PERMIT Charges and Surcharges ELECTRICAL PERlHT Charges and Surcharges MECHANICAL PERMIT Charges and Surcharges I"FORllATlON UNl 726-37S3 Sq. Ftg. Hain ~q. Ftg. Access. Sq. Ftg. Other New Add Alter Rep. --Fence Demo Change/Use Other - - ~ ~ ~I ~ ~ ll'!xnirl'!s) I I fohone no:) " _-1"-- , y~\ .y","", (p1l'n;,.pc;,l (I')hnnp nn 1 MECHANICAL I t't't' I r furnace/burner to BTU's Floor furnace and vent Recessed wall ~n"rp hp"t~r "nrl v~nt Appliance vent seDaratp S-tationary evap. cooler Vent fan with sinole duct Vent system apart from , heatino or A.C. I Mechanical exhaust hood "nd riurt I ~lood stove/heater , , , I I Value Value Value TOTAL VALUATION Systems Development Charoe tl.5S) . . . Irotal Comb.. rennit I , TOTAL IS, ~D' p~ 'l - ~"- ~- . r. '-'0 COMBINATION APPLICATION/PERMIT (CAP) I. Applicant to furnish A. Job Address ' B. Legal Description 1. ~xample- Tax lot 100, lane County Map. Ref~rence 17 03 43 2. example- Lot 1. Block 3. 2nd Addition to .Sprlngtield Estates C. Name, etc. of owner and construction lender u. Energy Sources 1. example- heat/electrical ceilinq/or forced air Qas 2. exam~le- waterheater/electrlcallor solar E. Square footage or valuation, etc. . 1. example- 1250 sq. foot house. 500 sq. foot garage 2. . exanple- if new project, check new. - if addition, cneck add~ etc. F. Building permit information:. 1. examDle - construct single family house with an attached garage . . 2. examDle - 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 ~ivision 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 fonm 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 O. 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 b~ 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. " PERMIT VALIDATION /~~.:: JIJO VJd(p J\{) ~ /1) ." , u(\ / V. FOR OFFICE USE ONLY Permit Clerk (f/ PROJECT CONDITIONS TO 8E SATISFIED BEFORE OCCUPANCY: './1 'V Permit applicant exempt from regi~tration with.the Builder's Board because: Additional'Project Information: PLANS REVIEWED BY: name signature; date " ~. ~-"""'''-':_'' ",~-'--~-~~;!-:~. , ,...~._... .' .,f' '. ..--.I- \. " ;. .. ~. ft.'(1l'I'\(~~V,"!, .r.?~~~..~'I\'I,' ~'" .... ""."""'.. , " t t. t " _j , .:> \.."'.".... j \ .".......,,\:v,~,~~; ,r!o,'''., .~",,, "'i1.4\~" ~ .' .' ',. '. PRING FIELD UTILITY BOARD 250 North "A" St. Springfield, Oregon 97477 BACKFI.:OW DEVICE TEST REP.ORT FIRM NAME' /1/,1 1.f'/2;c,. ... _~. " . 1/ , t 7.' '-;,j,1J":; );-7r ::- 5'/ r:":o.J :.; ., , ~?70 rFld.I'v ADDRF~C;;:' ..... ~'/.:: f'. " 0:). "':'/ SIZE . 7 ,MODEL () ". '..> / . SERIAL # j.~ /0.;;:1,::::, I- '" w I- -' <( E z New Parts and/or Repairs Made I f Needed final Teu After Repairs ". j'....' ./...- /'1 ~ :7" ....,. PASSED: (.{.." //:5:<' FAILED: tin. TESTER: ; , ()~. /i--- " /7 / <J (/ /.' , c.C(..7<.".'. ,._ ',. CERTIFICATION ':;' 3' '/ # /.j- ,/"" LOCATION OF DEVICE: IY/,' REDUCED PRESSURE DEVICES OOUBLE CHECK VALVES Pressure Drop Across , Check 7.(. Opened at 3. C' lb.. DATE: TESTE R # NAME: Ibs.1 'DATE: I CERTIFY THE ABOVE TEST HAS BEEN PERFORMED, Bya~~?~:.,-_ L Check Check #1 #2 Lea~ed ( I Leaked ( I .closed ':;Iosed Tight .!X1. Tight J><:! Relief Valve C~efk CJ}eik I Relief Clo~ed Closed Valve Tight Tight Opened at ( J ( I (COMPANY OFFICER) r~ &-pf , ,. . .: . . , " " , , '. ~ :,. '. . , , ':I~{I"