HomeMy WebLinkAboutPermit Backflow Test 1989-2-17
,'. --
QISI'ECT 1011 L111E
726-3769
Job Address
1506
leqal De~cription
, .
Owner
'\Jdrcsk:::79,2 f:((nn '7
t;. ~ () (fA....Q
Construction Le~er
Address
Ut~llirj ILJ\/l
[name I
Primary
Structural
Electrical
~1echanical
CONTRACTORS
(nampl
\1
--. --"..
Lliy',iF SI'RIlMIELO
~ CmlBlllATION APPLICATION/PERMIT .
or> ,^ ) I E!IERGY SOORCE?:'
~ Ueat
! Ua tel'" Ilea tel'"
RanlJe
i Valu, 01 Hark:
Plumbinq
1
(JA)) nJl/v../
~'
'7~~/7/J/ . . (I '/l.A /
S UI'71/'l1.f/uftUl}honc 3Cfc;
OK /t/hK'
Genera 1
Electrical
nechanical
PLUr1B !rIG
l'jO. r
-, Each sin91e fixture
-,Relocated building
(new fix. additional)
Is.F. Residence
(1 bath)
I Duplex (1 bath) each
IAdditional bath
I ~!a tel'" serv i ce
jSewer
Storm Sel-/er
/l.va.da tm;)u
I
I
~, *\-l4) I
/ a....P'
v
q,j{1...
TOTAL CHARGES
HHEP.E STATE L.\II REQUIRES
shall not be valH until the
FFF I CIlI\Rr.f Jln
I
I
I
I
I
I
I
I/~PO
I
I~.OO
/)5,00
1 I
13.~O I
.1 TOTAL
NFORltAT: .:1 LI..::.
726-3753
So. FtQ. '.lain
~Q. n9. Access.
SQ. Ftq. Other
rle\'t Add ~.1 tel'" ~eD.
--Fence Demo Change/Use
Other -- --
Phone
(address)
Ouih;ino Permit Info:
F ar.Ji 1v nes i dence I.Iith
(l;1l/../~ J
. ~ d;;'../l'O I
I tJ
Describe Work{i.e," Build Single
f\.ttached (;araoel
/30 r ~>.
./
(I ics. no. I
lexoirpCj,)
(ohone nO.1
(address )
110
--JL,
.~
II 1(s. no.)
J~'
~ ~~q
(p)(l)i1'"pd
(nhnf'lp nn
1_
c.1.00
1 -
)"1\
//,
ElECTRICAL
I
m rU1.Jll!.....
-,-
I
I
I
I
I
I
I
\.I~nt
MECHANICAL
'"
QJARliJ
ReCj,idence of
furnace/burner to
BTlI's
SQ. FT.
I
I
I
I
I
1
I New circu~ts alls.
or extenSlons
ISERVICES
I
I Floor furnace
and vent
I Recessed wa 11
I ~o;!rp hp",tpr ;ilnrt
ITemporary Construction
IChange in existing
rpsid~nr~
Imultifamily. Conf!l. or
Inr1llc:tria.l
IOf
ICOI~'1.IINO. FEEDERS
/Install/alter/relocate
rlic:trih_ fppdprc:
101 amps. I
I I
I
I
amps.1
I APDI iance vent
c;poal'atp
I Stationary evap.
cooler
I Vent fan with
sinole duct
I Vent system apart from I
heatino or A.C.
I Hechan lea I exhaust '
hood and durt
I "load stove/heater
^
7\
I SSUANCF or PFR/IIT
I TOTAL CIIARGES
CHMGES
that the Electrical work be done by an Electrical Contractor. the electrical portion of this pemit
label has been signed by an Electrical Supervisor and returned to the Building Oivislon
I HAVE CAREFUllY EXNlItl(D t1e completed apr1ication for !:lermit. 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 Sori ng fi e 1 d and the Laws of the S ta te 0 f Ore~on oerta i n i 09 to the work descr i bed here in. and tha t 110 OCCUPAUCY ,.,i 11 be made
of any structure without the permission of the Ouilding Division. I further certify that II1Y re!}istration \'/ith the Builder's
Board is in full force and effect as required by Or.S 701.055, that if exemDt the basis for exemotion is noted hereon, and that
only subcontractors and em['lloyees \.,ho are in com:>liance with OP.S 701.055 \'/i11 be used on this project.
IIA:IE(please print~lrv. ,'\hf'n. r
- -'.....,
lone Tyoe/Cons t.
Fire Zone Bedrooms
Flood Plain Stories
BUILOillG PERI.lIT
Charges an~
Surcharges
PLU'1BING PERMIT
C~arges and r
Surcha rgeCj, '"7
. ELECTRIU.L rEnr:IT
Charqes and
Surcharges
r1ECHANICAL PERlilT
Charges and
Surc ha rges
Uni ts
Occy Load
Occy Group
SIr.tlAT~ kl\A~
FOP. OfFICE USE Oijlro~
Sf!. Ftn. flain x
Sq. Ftg. AcceCj,s x
S.,. Ftg. Other x
Value
Value
Value
~AHJ. 17' X'9
TOTAL VALUATIOn
I
Isystems Development
CharQe (1. 5")
ITotal (amb. rermit
I iOTAL
0..3. bO
Plan Ck. Comm/lnd
____________ 65t/Bldn Ppr Fpp
Plan Ck. R-es
30t/Bldo Per Fee
/'-0 ()O I Fence
------~ :...~--
3, 00() I Offmo
_ ___ _ _ ___ ___I ~i-dewa~k
I A/C Pavinq
lcurb Cut
.
.
-'
COMBINATION APPLICATION/PERMIT (CAP)
PERMIT VALIDATION
J. Applicant to furnish
A. Job Address
B. Legal Description
1. example- Tax lot lOa, lane County Map Reference
II uj 43
2. .xample- Lot I. Block 3. 2nd Addition to
~prlngtield Estales
C..' Name, etc. of owner and construction lender
D. Energy Sources
1. exampl~- heat/electri~~l ceil1n~/or forced air Qas
2. examole- waterheaterfelectrlcal/or solar
- E. Square footage or valuation, etc. -
1. examoJe- 1250 sq. foot house. SOD sq. foot garage
J 2. example- if new project. check---riew _ if addition,
, check: add. ete.
F.' Building permit inlormation:
1. examole - construct single family house with an
attached garage
2.- examole - remodel existing garage into family room
3. examOle - convert single famiJy residence into
restaurant (change of use)
G. Value of work as defined in Section 303 (a) of the
Structural Specialty Code
H. DESIGN 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 fi11.1n 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 fonm the schedules
have been abbreviated
Z. 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. Appljcant 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.
,
1j~2-1
d-~tl'-~J
V. FOR OFFICE USE ONLY
Permit Clerk
LL-
PROJECT CONDITIONS TO BE SATISFIED BEFORE OCCUPMICY:
~
:~.
.
..
1.
Permit applicant exempt from registration with .the Builder's Board because:
Additional Project Information:
PLANS REVIEWED BY:
,
name
signa ture
date