HomeMy WebLinkAboutPermit Backflow Test 1987-8-12
BU11<;lnQ Pennit Info: Describe \'!ork(i-.e., Build
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TOTAL CHMGES I TOTAL CHARGES
that the Electrical work be done by an Electrical Contractor. the electrical portion of this perr.lit
label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFULLY EXN1INED 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 Soringfield and the Laws of the State of Orel]on pertaining to the work described herein, and that IlO OCCUPAllCY \'/ill 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 subcontractors and employees who are in compliance with ORS 701.055 will be used on this project.
SIG'IATURE I.//Jn t) /Ja:A
1 IrISPECTIOtl LItlE
726-3769
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CiTY Of SPRINGFiELO
CorlBiilATION APPLlCATION/PERMlT
EilERGY SOURCES:
Heat
Ha ter Hea ter
Ranqe
ValUE of l'/ork:
.
Ii
/fls JYl tJ/.4f,
Legal Description Jif() "13 (/') -=? / () 1tj()(
Owner fh,i//;/J Ibj-o il'ittd
Address jirsd m tLt~
Job Address
Phone
Construction Lender
Address
OESIGrI rEAl1
Phone
(address )
(name)
(1 ics. no.)
; Primary
Structura 1
Electrical
!1echanical
CONTRACTORS
(name)
(address)
(lief;, no.'
Genera 1
Plumbina
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Electrical
I d
~G
ELECTRiCAL
,11. / . /7
If(t?dt~
;20 - '/s-;u6
~lechanical
1m, I FFF
Each single fixture
Relocated building
(new fix. additional)
rHARr,f ~)(\ I
IResidence of
SQ. FT,
New circuits alts.
or extensions
~n n-lARr.~ rm
S. F. Residence
(1 bath)
Duplex (1 bath)
SERVICES
each
Additional bath
I ~Iater service
Sewer
Temporary Construction
Change in existing
rp~;1pnrp
Imultifamily, camm. or
Inrluf;tritll
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~fD
10f
ICor~II./IND. FEEDERS
I Install/alter/relocate
rlif;trih_ fpprlpr~
Of amps.1
Storm Sewer
amps.1
4)
V
TOTAL CHARGES
WHEnE STATE L~W REQUIRES
shall not be valij until the
ilAr'lE(please print) \1/ /I).
J2 AIl....[:y'
v.!.
Zone
Fi re Zone
Flood Plain
Fon OfFICE USE QillY
Units Sq. Ftg. riain
Occy Load Sq, Ftg. Access
Occy Group Sq, Ft9' Other
Tyoe/Cons t.
Bedrooms
S tori es
BUILDING PERI.IIT
Charges an'::
Surcharges
Plan Ck, Comm/Ind
65X/Bldo Ppr Fpp
Plan Ck. Res
3D%/Bldo Per Fee
Fence
~~~~;~~G a~~RM~/ _ n __ j Q-'. ~~_
Surcha rges -, . '6
ELECTRICP.L PERI~IT
Charges and --------____
Surcharges
Demo
\
Sidewalk
I A/C Pavi ng
I Curb Cut
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11ECHANiCAL PERMiT
Cha rges and
Surcharges
i1IFORtIA TI ON WI< I
726-3753
Sq. FtQ. I,lain
~q. Hg. Access.
So. Ftg, Other
rle\~ Add Alter ~ep.
--Fence Demo Change/Use
-Other - -
Single
D<,1
c5
~
'~
II,~
(exnires) (ohone no, I
4
<1<"1 ~~ "(l~
(pxoirpf;) (ohnnp nn, \
'1t.:b\lLf
I() -,.) c/ - '(~
MECHANICAL
H'~ njAI?r.~
furnace/burner to
BTlI's
Floor furnace
and vent
Recessed wall
~otlrp hptltpr tlnn vpnt
Apoliance vent
~f'oartltp
Stationary evap,
cooler
Vent fan wi th
sinale duct
Vent system apart
heatina or A.C.
Mechanical exhaust
hood and duc-_f.
from
Wood stove/heater
ISSUANCF OF PFRtlIT
Dm~J;2~,\'->-
v
x
x
Value
Value
Value
x
TOTAL VALUATION
Systems Development
Charge (1.5~)
Total Comb. Permit
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IS: 7S
I iOTAl
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COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I. Appl icant to furnish
A, Job Address
B. legal Descriotion
1. examole- Tax Lot 100, lane County Map Reference
J/ 03 43
2. example- lot J. Block 3, 2nd Addition to
Sprlngtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources , "
1. examole. heat/electrical ceilinQ/or forced air qas
2. examole- waterheater/electrical/or solar
E. Square footage or valuation, etc. -
J. 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. example - construct single family house with an
attached gar~ge
2. examole - 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 TEAI.I 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 Mechani~al 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
ha've 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 ANO
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.
'Bfr;?ft 3
g ~ ( 2- -f 1
V, FOR OFFICE USE ONLY
Permit Cl erk
cu
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
,
Permit applicant exempt from registration with thiBuilder's Board becaus~:
Additional Project Information:
PLANS REVIEWED BY:
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name
signature
date