HomeMy WebLinkAboutPermit Backflow Test 1986-12-16 . . IIIlSPECTIOIl LlrlE 726-3769 . , 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 - - I \..-~_~I -o'~i- Owner Ww!U(il- ~!l1~ I Address (/l-.::s t!J L/ M~ Phone I/L(( //11 .,;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., /' 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 '\