HomeMy WebLinkAboutPermit Backflow Test 1987-12-10
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CITY OF SPRINGFIELD
COMBINATION APPLICAT10N/PERMIT
EilERGY SOURCES:
Heat
14ater Heater
Range
Valu€ of Work:
..
I INSPECTION LINE
726-3769
INFORllATION LINe
726-3753
Sq. Ftq. 1.lain
~q. Ftg. Access.
Sq. Ftq. Other
flew Add Alter Rep.
--Fence Demo Change/Use
-Other- -
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Job Address
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Sit
legal Oe$cription
i:k..o (\ 0/\. .. r ..dNt-J
I<.~{) I4)..Ji, '10, Al
C( LA C-I__ 00 /\I) q'\lOA
Construction Lender 0 ,.;.. -
Owner
(.,'8~-o<Q(
Address
Phone
Builri;nQ Permit Info: Describe Work(i.e., Build Single
Familv nesidence With Attached Garaoe)
Address
OES I G" 1 EAr'I
(name)
Phone
(address)
(lies. no.)
(exoiresl
(ohonp
J
Primary
Mechanical
CONTRACTORS
Inamel
(addrflss\
(lire 1'10.1
(pyrd rpc 1
~
'"n""...", n,'" \
Structura 1
Electrical
t?~4 ' !; ;CI V
Genera 1
Plumbino
(li-'(U
Electrical
~'echanical
PLUrlBING
ELECTRICAL
MECHANICAL
NO.1
I HF 1 rHARr;F NO I
I ~~~ I rI.lARr.:~ ~m I
I ~~!:' I rl-l.l1q,GL
Each single fixture
Residence of
SQ. F1.
furnace/burner to
BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor furnace
and vent
S.F. Residence
(J bath \
Duplex (1 bath) each
Additional bath
SERVICES
Recessed wall
~~~~p hp~tp~ ~nrl vpn~
Storm Sewer
Of
amps.
Appliance vent
seoaratp
Stationary evap.
cooler
Vent fan with
~inole duct
Vent system apart from
heatino or A.C.
Mechanical exhaust
hnod and nu~t
Sewer
Temporary Construction
Change in existing
rps i dJIJ1f'p
multifamily, comm. or
Tn~lJl:tri""
~Jater service
COMM./IND. FEEDERS
Install/alter/relocate
r1idrih_ fpprlprc;
Wood stove/heater
~{, V~C-V
Of
amps.
I
171
ISSUANCF OF PFRllIT
I TOTAL CHARGES
Electrical Contractor. the electrical portion of this permit
Supervisor and returned to the Building Division
TOTAL CHARGES TOTAL CHARGES
WHERE STATE L'H REQUIRES that tile Electrical work be done by an.
sha~l not be valid until the label has been signed by an Electrical
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 rlO OCCUPAr~CY 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.
NAf.lE(please print)
Zone
Fi re Zone
Flood Plain
Tyoe/Cons t.
Bed rooms
Stories
Units
Occy Load
Occy Group
SIGNATURE
FOr. OFFICE USE OIIL Y
Sq. Ftg. 11a;n
Sq. Ftg. Access
Sq. Ftg. Other
OATE
x
Value
Value
Value
x
x
TOTAL VALUATION
BUILDING PERflIT
Charges anG
Surcharges
Plan Ck.
____________ 65%/Bldo
Plan Ck.
30%/Blda
JSDO I Fence
_nu ~~-f-I 0_
I'Sidewalk
I A/C Pavi ng
I Curb Cut
------------
I
COllll1/1nd
Ppr Fpp
R"es
Per Fee
Systems Development
Charae (1.5~)
PLUl1BING PERMIT
Charges and "
Surcharges '?
I
I
I
ELECTRICAL PERI~IT
Cha rges and
Surcharges
11ECHANICAL PERMIT
Charges and
Surcharges
ITotal Comb. Permit
I
I TOTAL
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IS.jS-
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,
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
1. Applicant to furnish
A. Job Address
B. Legal Description
I. example- Tax Lot 100, Lane County Map Reference
17 03 43
2. examele- Lot I. Block 3, 2nd Addition to
Sprlngtield Estates
C. Name, etc. of owner and construction lender
D. Energy Sources
1. example- heat/electrical ceilinq/or forced air qas
2. exalllPle- water'heater/electricafior solar
E. Square footage or valuation, etc.
I. 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 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. OESIGN TEAM ANO 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 OOT ALL FEES AND
CHARGES ON THE SCHEOULES
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. ---
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 ;s 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.
{ 0&51
12-- (0 r~ 7
V. FOR OFFICE OSE ONLY
Permit Clerk
CC/
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