HomeMy WebLinkAboutPermit Backflow Test 1986-12-16
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IIIlSPECTIOIl LlrlE
726-3769 .
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INFOR/IATlO;t U:lt
726-3753
So. Ftq. f.lain
~q. ::tg. Access.
Sq, Ftg. Other
lie" Add A,lter ~ep.
--Fence Demo Change/Use
Other - -
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\..-~_~I
-o'~i-
Owner Ww!U(il- ~!l1~ I
Address (/l-.::s t!J L/ M~ Phone I/L((
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.,;l2 f'cJ /Jf I2t4u
Job Address
Construction Lender
Buil(iiM Permit Info: Describe Hork{i-.e.. Build
FJ;;M;t~YtJ)u;'
p/lJ' AN 4/Z(~ /AJ.-r/iLV
Single
00
6'
o
Q
c:::,
-.......::::
LelJal Description
ValuE of I-lark:
Address
Ul:.:>llifl H.Af,'
lnamel
Phone
(address)
!lies. no.)
lexnires)
(ohone no. l
Structural
('
;:..
6"1~
)I~O ,.I
J~V/
Primary
t1echanical
CONTRACTORS
(namel
(address)
(1 iC5. no.l
(pxoi rps)
\~
~t
(~~hnnp nn )
Electrical
General
~J.,
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Plumbina
Electrical
f.1echanical
PLUllBllIG
ELECTRICAL
MECHANICAL
1/0. I FFF
Each single fixture
Nn
"CLIJ:l!AB.IiI: Nn
11=171=
,
I r':!ARG..E...1
Relocated building
(new fix. additional)
S.F. Residence
(l bath\
Duplex (1 bath) each
I CHAReF
I
I
I
Residence of
SQ. FT.
furnace/burner to
BTU's
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
~n~~p hp~tpr ~nrl vpnt
Sewer
Temporary Construction
Change in existing
rp} i dJ'prp
Imultifamily, comm. or
Tndllc;,trial
IOf amps.1
1 COI~'I.IINO, FEEDERS
1 Install/alter/relocate
dic;,trih, fppdprc;,
Of amps.1
I
I
I
I
I
I
I TOTAL
Appliance vent
c;,poarat.p
Stationarv evao.
cooler ~ .
Vent fan with
<;.inale duct
Vent system apart from I
heatina or A.C.
Mechanical exhaust
hood nnd c1urt
I'!ood stove/heater
Additional bath
~!a ter servi ce
Storm Sewer
......A
I SSUANCF OF PFRrllT
TOTAL CHARGES
WHERE STATE L~W REQUIRES
shall not be valij until the
TOTAL CHARGES
CHARGES
that tile Electrical work be done by an Electrical Contractor, the electrical f1ortion of this pernit
label has been signed by an Electrical Supervisor and returned to the Building Division
I HAVE CAREFUllY EXA/'lINED the completed apfllication for germit, and do hereb.v 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 Orel]on pertaining to the work described herein. and that flO OCCUPAIKY 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 subcontractors and employees who are in compliance with OP.S 701.055 will be used on this project.
11AI'IE(please print)L! Ii-ff'MA ..41 <!/,j/T/A'" F
SIGIIATURE ~ m ~-4:'
OATE /;;>-/6-!f,
FO~ OFFICE USE DillY
Zone Tvpe/Cons t. Units Sq. Ftg. f1ain
Fire Zone Bedrooms Occy Load Sq. FtlJ. Access
Flood Plain Stories Occy Group Sq. Ftg. Other
x
x
x
Value
Value
Value
TOTAL VALUATION
BUILOlltG PER~IIT
Charges an~
Surcharges
Plan Ck. Comm/lnd
65X/Bldo P?r Fpp
------------ P"fan Ck. Res
30%/Bldo Per Fee
_nn_~-?-:':3_~1 Fence
. (PO Oemo
Systems Development
CharQe 0.5%)
PLU'1BING PERMIT /
Chilrges and s..
Surcha rges
ELECTRIUL PERI~IT
Charges and
Surcharges
/lECHAN I CAL PERMIT
Charges and
Surcharges
Sidewalk
AIC Paving
____________1 Curb Cut
I
ITotal Comb. rermit
1-
I'OTAL
15.00
.
.
.
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
l. Applicant to furnish
A. Job Address
B. Legal Oescription
1. example- Tax Lot 100. Lane County Map Reference
17 03 43
2. example- lot 1. Block 3, 2nd Addition to
sprfngtield Estates
C. Name. etc. of owner and construction lender
D. Energy Sources
1. example- heat/electrical ceil;nqlor forced air Qas
2. exampJe- waterheater/electr;cal/or solar
E. Square footage or valuation, etc. -
I. examole- 1250 sq. foot house, 500 sq. foot garage
2. examp.le- 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. examyle - 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 TEAl.! 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. BUILOING OIVISION STAFF WILL FILL OUT ALL FEES ANO
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 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.
~fo75b:J
f J- -fro r~0
V. FOR OFFICE USE ONLY
Permit Clerk
cv
PROJECT CONDITIONS TO BE SATISFI ED BEFORE OCCUPANCY:
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
I
PLANS REVIEWED BY:
J
name
signature
date
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