HomeMy WebLinkAboutPermit Backflow Test 1984-9-18
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JINSPECTION LINE CITY OF SPRINGFIELD
726-3769 COMBINATION APPLICATION/PERMIT
.--y)? E!lERGY SOURCES:
Job Address J$./S //((j/~; _ Heat
Legal Descnptlon \"'h..::p;~4 \ h~aJ I~ater Heater
Range
INFORlIATlON LJNl
, 726-3753
Sq. Ftg. 1,Iain
~q. Ftg. Access.
Sq. Ftg. Other
Ilew Add Alter Rep,
--Fence Demo Change/Use
Other- -
IV'
i"-S)
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C:l
~
llXl
no,
Owner J.."Jj /JA A;' A P , -7J1 ~ / JlP.A .J
Addres~J//;';> ~...A', M. Phone 7'-1 1-
constructi~3" J'b9/
Valu' of YWk: ~-'
Yf ,ISO. V,V
Builriino "Pennit Info: Describe Work{Le., Build Single
Family nesidence With Attached Garaae)
.~dn-f~ I .../~~I/AJAJ
J:JA../l-,AL.J/~L di?_~J... ,
,
Address
DlSIGN TEAI1
(name)
Phone
(address)
, (lies. no.)
(exo;res)
(ohane
Primary
,~~
,~
Structural
Electrical
Mechanical
CONTRACTORS
(namel
(address)
(lies. no.)
(pxoires) (Dhnnp nn.)
General
Plumbina
A?-< -' r-v'1 ~
Electrical
"lechanical
PLUlIB I NG
ELECTRICAL
MECHANICAL
NO,
FEF cHARr,F Nn
~~~ r~AQr.~ NO
!:!:~ I rUllof.:t: t
Each single fixture
Residence of
SQ. FT.
furnace/burner to
BTU's
Relocated building
(new fix. additional)
New circuits alts.
or extensions
Floor fu rnace
and vent
S.F. Residence
(1 bath)
Ouplex (1 bath) each
Additional bath
SERVICES
Recessed wall
Sn~~p hp~tpr ~nrl vpnt
Storm Sewer
....L tZ~/.f~!lAP.J, S'"
('~"f!O.VD La)
V /
Of
amps.
Appliance vent
s.eoarate
Stationary evap.
cooler
Vent fan wi th
sinole r1urt:
Vent s.ystem apart from
heatina or A.C.
Mechanical exhaust
hond ~nrl durt
~Ia ter servi ce
Temporary Construction
Change in existing.
rp) i rte.nrp
multifamily, comm. or
Tnrluc:.triill
Sewer
COMM,/IND, FEEDERS
I Install/alter/relocate
dic;trih. fppdprc:.
jOf amp~
I
Wood stove/heater
TOTAL CHARGES
WHERE STATE L~W REQUIRES
shall not be valij until the
Jt) otJ TOTAL CHARGES
ISSUANCE OF PFRilIT
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
Fi re Zone.
. Flood Pla;n
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 UO OCCUPAHCY 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 exemption is noted hereon. and that
only subcontractors and employees who are in comoliance with OP.S 701.055 will be used thl n~ject.
IWIE(please pr;nt.0c>h IV^,I E. HI LL.E:R SlGII^~ DA~ ",,' 9 , '
Fo~"orFlm:-USE qnLY
\ _Sq/Ftg, Ila;n
Sq. Ft9, Access
Sq, Ftg, Other
DATE 9-/?-&
Zone
Tyoe/Const.
Bedrooms
Units
Occy load
Occy Group
x
Value
Value
Value
x
Stories
x
TOTAL VALUATION
BUILDING PERmT
Charges and
Surcharges
Plan Ck. Comm/lnd
65%/Blda P.fr Fpp
------------ Plan Ck. Res
30%/Bl do Per Fee
Systems Development
Charoe (l,5~) .
~
PLur1BING PERMIT
Charges and
Surcharges
______L9-'~_ Fence
. t./o I D/jRlo
I SIdewalk
I A/C Paving
I Curb Cut
I
Total Comb. rermit
ELECTRICAL PERr:IT
Cha rges and
Su.rcha rges
/lECHANICAL PERMIT
Charges and
Surcharges
I
I TOTAL /0. {/O
/O~~
-
,
?:'40""'3
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
I, Applicant to furnish
A. Job Address
B. legal Description
I, ~xample- Tax Lot 100, Lane County Map Reference
II 03 43
2, exam~le- 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. examole. waterheater/electrical/or solar
E. Square footage or valuation. etc. -
I. example- 1250 sq, foot house, 500 sq, foot garage
2. example- if new project. check new - if addition,
check add. etc.
F. Building pennit information:
1. exam~le - construct single family house with an
attached garage
2. example - 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 TEM1 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 OUT ALL FEES AND
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 penmit 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.
fl.#- b'JS73
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V. FOR OFFICE USE ONLY
Permit Cl erk
tP;J.
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
I