HomeMy WebLinkAboutPermit Backflow Test 1983-8-23
I INSPECTION LIIIE
726-3769
Job Address ~
Legal Description
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Owner (.::.il~ -Prrif t-,~flY) ..
Addres~ ~ ( J- : Do ~ 1\ Q::t .. r Phone
con~ L~e~ > f)Jj t? ~n35d
CITY Uf SPRINGFIELD INF0R11ATlDN LINt
COMBIIIATION APPLICATION/PERMIT 726-3753
Y'Y) A)j'AjJJ ~~n~n-t- EIIERGY SOURCES: ________ Sq, Ftg, 1,Iain
A J ,~ , n~ Heat ~ :q. Ftg. Access. ~
Hat~r He Sq, Ftg, Other~
New Add Iter Rep.
Ran --FenC- erno Change/Use
VaiuE of Hor,u/ k -0 r -
Builoln<:l Pennit/ Info: DeSCf.ibe Work.(;.,e., Build Single
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Address
Ut~ I uN n~Ar~
(name)
Phone
(address)
(lies. no.)
(exoires) (ohane no.)
Primary
t
~A
ifr
Structural
Electrical
Mechanical
CONTRACTORS
(name)
(address)
(1 il':C';.. no.)
(exoirec;,) (nhonp nn.)
Genera 1
Plumbino
Electrical
~1echanical
PLUflBING
ELECTRICAL
MECHANICAL
NO,I
Each single fixture
I HF 1 r:HARGE' NO I I ~~~ I r"'AIU~1=' r-m 1
Res i dence of furnace/burner to
SQ, FT, BTU's
Il='n" I (,I-IAQi:~
i
,
Relocated building
(new fix, additional)
S,F, Residence
(l bath)
Duplex (1 bath) each
New circuits alts.
or extensions
Floor furnace
and vent
SERVICES
Recessed wall
Sn~rp hp~tpr ~nrl vpnt
Sewer
Temporary Construction
Change in existing
r~c;.jdp'_nr.p'
Imultifamily, eQII'm. or
, Tndu<:;trial
IOf amps.
ICO~1,/IND, FEEDERS
I Install/alter/relocate
rlidrih. fpprlprc;;
IOf amps.
I
I
I
Appliance vent
c:eOal"i\te
Stationary evap.
cooler
Vent fan wi th
sinole duct
Vent system apart from
heatina or A.C.
Mechanical exhaust
hone! <lnd rlurt
Additional bath
\oJater service
Storm Sewer
Wood stove/heater
ISSUANCE OF PERrllT
TOTAL CHARGES TOTAL CHARGES TOTAL CHARGES
WHERE STATE L'\~ REQUIRES that the Electrical work be done by an,'Electrical Contractor, the electrical portion of this permit
shall not be valiJ until the 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 NO 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 7nl.055 will be used on this project.
Zone
Fire Zone
Flood Plain
"
Tvpe/Cons t.
Bedrooms
Stories
I'
Units
Occy load
Occy Group
SIGIIATURE ~~~
FOP. OFFICE USE lOiIrY ~ - ..."
Sq. F~r1ain x
DATE~4J
I~AI'IE(please print) Vf'rr.v ~///.'7>
-'
Sq, Ft~, Access
Sq, Ftg, Other
x
Value
Value
Value
TOTAL VALUATION
x
BUILDING PERI1IT Plan Ck, Conm/Ind
Charges ant: ------------ 65%/Bldo ppr ~"'e
Surcharges Plan Ck, Res
30%/BldQ Per Fee
PLUl1BING PERMIT ___LQ~5-!.'2_ Fence
Charges and
Surcha rges , 40 Dlj1!1O
ELECTRICP,L PERI~IT 'Sidewalk
Cha rges and ------------
Surcharges A/C Paving
IIECHANICAL PERMIT I Curb Cut
Charges and ------------ I
Surcharges
Systems Development
Charoe (1.5%) . '.
Total Comb, Permit
TOTAL
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COMBINATION APPLICATION/PERMIT (CAP)
I, Applicant to furnish
A. Job Address
B, Legal Description
I, example- Tax Lot 10D, Lane County Map Reference
II U3 43
2, example- Lot 1. Block 3..2nd Addition to
Sprlngtield Estates
C. Name, etc. of owner and construction lender
D, Energy Sources
1. exa~le- heat/electrical ceilin~/or forced air Qas
2. example- waterheater/electrlcaltor solar
E. Square footage or valuation, etc. -
I, examp1e- 1250 sq, foot house, 500 sq, foot garage
2. exam~le- if new project. check-new - if addition,
Checlc add. etc.
F. Building pennit information:
1. example - construct single family house with an
attached garage
2. exam~le - 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, DESIGN TEN1 AND CONTRACTDRS
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 OUT ALL FEES AND
CHARGES DN 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.
V, FOR OFFICE USE ONLY
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPANCY:
.
PERMIT VALIDATION
~wsLJ3\83
19 \ SC13
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Permi t
,
C1 erk'Fh (!Xl )
.
Permit applicant exempt from registration with the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
name
signature
date