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Home My WebLink About4509 Old Mill Rd - Engineering -~~ ';R'~tii;f~Btt:-.{t~{~; ,j: CITY OF PORT ANGELES DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DNISION 321 EAST 5TH STREET, PORT ANGELES, W A 98362 0 ~ -- J;;? '1 Application Number Pin number Property Address ASSESSOR PARCEL NUMBER Application description Subdivision Name Property Use Property Zoning Application valuation 03-00001214 Date 055170 4509 S OLD MILL RD 06-30-22-2-1-9000-0000- RES NEW SFR 3/17/04 RS9 RESDNTL SINGLE FAMILY 135939 Owner Contractor GRAY, RANDY/JENNIFER 31 NELLO PLACE SEQUIM (360) 683-2318 Structure Information Construction Type Occupancy Type Other struct info WA 98382 ANDERSON HOMES LLC 618 SOUTH PEABODY PORT ANGELES (360) 452-4641 NEW 2089SF SFR W/ATTACHED 736SF TYPE V NON-RATED SINGLE FAM & CONGREGATES TOTAL % LOT COVERAGE CONSTRUCTION TYPE NUMBER OF STORIES EXISTING LOT COVERAGE LOT SIZE PROPOSED LOT COVERAGE TOTAL LOT COVERAGE NUMBER OF UNITS WA 98362 GARAGE 18 50 V-N 1 00 1 00 17460 00 3233 00 3233 00 10 00 640 00 3/17/04 9/13/04 Plan Check Fee Valuation 00 135939 JJo S4h Sew €JY' W 1 L.A_- C3e- Or, Sept) G Permit Additional desc permi t ~ Fee-. Issue Date Expirati.on, Date PUBLIC WORKS RES WATER SERV Qty Unit Charge Per Extension 1 00 640 0000 EA PW W/M SFR 5/8" ~40 00:> ----------------~------------------------------------------------~ Permit RIGHT OF WAY Additional desc Permit Fee Issue Date Expiration Date 45 00 3/17/04 9/13/04 Plan Check Fee Valuation 00 135939 Qty Unit Charge Per E~tens' 1 00 45 0000 ECH RIGHT OF WAY PERMIT 45 OO~ ------------------------------------------------------------------- --------~ ~Special Notes and Comments Down spouts from roof gutters shall be piped to drywells or may be piped to curbs that flow to strom drains No pressurized or pumping to curbs are allowed Address numbers shall be plainly visible from the street Address numbers shall be a minimum of six inches high and be in contrast in color of there background Electrical load calculations and elctrical permits are required 4' wide gravel walking surface per City stanards, required for school route Other Fees STATE SURCHARGE 4 50 Separate Pl;irmits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned for a period of 180 days after the work as commenced or if required inspections have not been requested within 180 days from the last inspection j-hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not p-reSllhie to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construcwn ~~a:;~<- Si9J;: of Contractor or Authorized Agent ;1' 0' '1 Date Date Signature of Owner (if owner is builder) T'IPLANNTNGIFORJvlSI] 102.1 'i [11/14/2001] \->>,\~1,~ ~i~S:(~t~~~~]~~~~j~~t~~~;i;~l;,~-~~~:;,. ," CITY OF PORT ANGELES DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DNISION 321 EAST 5TH STREET, PORT ANGELES, WA 98362 Application Number pin number Page Date 2 3/17/04 03-00001214 055170 ---------------------------------------------------------------~- Other Fees PW WATER SYSTEM USE FEE ~ Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 685 00 685 00 00 00 Plan Check Total 00 00 00 00 Other Fee Total 1029 50 1029 50 00 00 Grand Total 1714 50 1714 50 00 00 Separate Permits are required for electrical work, SEPA, Shoreline ESA, utilities private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days if construction orwork is suspended or abandoned for a period of 180 days after the work as commenced or if required inspections have not been requested within 180 days from the last inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construction Signature of Contractor or Authorized Agent Date Signature of Owner (if owner is builder) Date T',PLANNINGIFORMS' 1102.15 [11/14/2003] Date CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . . . . . . INSPECTION REPORT. . . . . . . . . . . IO/; ~~4 Time I ' j Received by -Iv j/ (phone, person) REQUEST Location of Work to be inspected Name of person requesting inspection Address of person requesting inspection Type of Inspection (circle appropriate one) Sewer Foundation Framing Chimney 4-srq U_~J M LQi) ,~, Phone No Permit No ~ IZP] Plumbin~sewer Excav Other {! J.;lt~ INSPECTION NOTES /; / Inspected Date ! {)/ '3 / (J f Time Remarks By "F , OK- RESTORATION REQUIRED. ... YES NO SURFACE RESTORATION. SURFACE TYPE D Unimproved DGravel 0 Asphalt 0 PCC o Other D Repaired by City D Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . INSPECTION REPORT. . . . . . REQUEST Date tf - 2 , - <-=' '-+ Time 7 ~k. Received by De- ~"'-\.~ E- (phone, person) Location of Work to be inspected <.f 5 0, C) (d. ~l ( { R...ti... Name of person requesting inspection D<:V\.~ :<; E ~ Address of person requesting inspection Lo II f '-I a.-r- &. Phone No t.f ( 7 - Lf~'i " Type of Inspection (circle appropriate one) Permit No Sewer Foundation Framing Chimney Plumbing Final Sewer Excav Other W~ +-L." 171/ 5. AlH1Se LV H....l-- P->€" D V\ 5 ep4-t G n 0 S6?n :sew €lt- A<; J4-1l..-~ INSPECTION NOTES Inspected Date Lf - 2- t ~ 0 <-( Time '3 0 f') (J M... By D-L"'-v\..\ ~ K;.. Remarks I-IP.l,- ko ~ a- I" y:! E 1-- vh, ~ It:.u...... J KLle r il (<l ~ \ C\ I? d!. I;-oc '^-- ~LJ 1)(... 5/8 ~ {~ C- OJS fP F- / g, 78' :3 9 I lIP .> RESTORATION REQUIRED YES NO >Z c",,{vir.} P. P- J1'lQ..te.r I \~t.~ up W~-t"'-l,,"p 01.'-< cs., si'l"~-t. (). - D.-.. ~ ~ W .-... ~ -- ~ ...J r'\ ~ ~ f'\ c. - < .~ ~ ""' ..,.. ~ ~ ~1 '" ~ ~ \J SOIJn.p;"op~ - G,''''~E'r /" SURFACE RESTORATION SURFACE TYPE D Unimproved 0 Gravel o Repaired by City [] Repaired by Permittee [] No Damage Found o Asphalt 0 PCC 0 Other Work Order # (~? 0 ~ - DZ-3 o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DA TE) BUILDING PERMIT INSPECTION RECORD CALL 417-4815 FOR BUILDING INSPECTIONS CALL 417-4735 FOR ELECTRICAL INSPECTIONS, PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED POST PERMIT IN A CONSPICUOUS LOCA nON KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE INSPECTION TYPE DATE ACCEPTED COMMENTS I YES NO FOUNDATION: FOOTINGS WALLS FOUNDATION DRAINAGE/DOWN SPOUTS ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT # ROUGH-IN PLUMBING UNDER FLOOR 1 SLAB ROUGH-IN WATER LINE (METER TO BLDG) GAS LINE BACK FLOW 1 WATER AIR SEAL WALLS CEILING -I 1 FRAMING JOISTS 1 GIRDERS SHEAR W ALLIHOLD DOWNS WALLS 1 ROOF 1 CEILING DRYWALL (INTERIOR BRACED PANEL ONLY) T-BAR INSULATION SLAB WALL 1 FLOOR 1 CEILING MECHANICAL HEAT PUMP GAS LINE WOOD STOVE 1 PELLET 1 CHIMNEY HOOD 1 DUCTS PW UTILITIES I SITE WORK (Engineering Division) SEPARATE PERMIT #'s: WATERLINE 1 METER SEWER CONNECTION SANITARY STORM PLANNING DEPT SEPARATE PERMIT #'s SEPA, PARKINGILIGHTING ESA, LANDSCAPING SHORELINE, FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED YES NO ELECTRICAL LIGHT DEPT 417-4735 ELECTRICAL LIGHT DEPT CONSTRUCTION R,W I PWI CONSTRUCTION R.W ENGINEERING 417 -4807 PW 1 ENGINEERING FIRE 417-4653 FIRE DEPT PLANNING DEPT 417-4750 PLANNING DEPT BUILDING 417-4815 BUILDING T'\P LANNINGIFORMS\1102,15 [11/1412003] BUILDING PERMIT INSPECTION RECORD CALL 417-4815 FOR BUILDING INSPECTIONS, CALL 417-4735 FOR ELECTRICALINSPECTIONS, PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED, POST PERMIT IN A CONSPICUOUS LOCA nON KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE. INSPECTION TYPE DATE ACCEPTED COMMENTS YES NO FOUNDATION: FOOTINGS WALLS FOUNDA nON DRAINAGE/DOWN SPOUTS ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT # ROUGH-IN I PLUMBING UNDER FLOOR / SLAB ROUGH-IN WATER LINE (METER TO BLDG) GAS LINE BACK FLOW / WATER AIR SEAL WALLS CEILING FRAMING JOISTS / GIRDERS SHEAR WALL/HOLD DOWNS WALLS / ROOF / CEILING DR YW ALL (INTERIOR BRACED PANEL ONLY) T-BAR INSULATION SLAB I I WALL / FLOOR / CEILING I I MECHANICAL HEAT PUMP GAS LINE WOOD STOVE / PELLET / CHIMNEY HOOD / DUCTS PW UTILITIES / SITE WORK (Engineering Division) SEPARATE PERMIT #'5: WATERLINE / METER SEWER CONNECTION SANITARY STORM PLANNING DEPT SEPARATE PERMIT #'5 SEPA, PARKING/LIGHTING ESA, LANDSCAPING SHORELINE, FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED YES NO ELECTRICAL LIGHT DEPT 417-4735 ELECTRICAL LIGHT DEPT CONSTRUCTION RW / PW / CONSTRUCTION R,W ENGINEERING 417-4807 PW 1 ENGINEERING FIRE 417-4653 FIRE DEPT PLANNING DEPT 417-4750 PLANNING DEPT BUILDING 417-4815 BUILDING l' \PLANNING\FORMSI1102,15 [11/14/2003] P,03/03 , -;')';;3$' .'};f:~,~l l~>.rrf..,.~"lid ;~i " '.1' ~' '\\:I~ d /,<' . .,,~I." ..'t,.J',\~B Section: ,'h:;,i:~~*~J ~:~::hi 0UJ7~,,;;~~~t . :. ..,r.'\';:~t. This reauest for permit is for the placement of underground [elephone seI'Vlce W1l'E!',P;{.t;'t[;;~ ')ur customer eH [he following address: . ii'it.:: , :~; .... ~S\;)~:,J ."., ,..." ~ ..~" .';1:i.;:;~:~1 ';,}::t~~~ '. ': ',:,~ ::'),;\:!~r ;!,I~ t" ~!H~,~"'J ~r, ":'?i:5r~i : " ":~ PAGE,03 **' JUN 04 2004 12:40 FR TRAFTON B Qwest Job # 253 471 W &- 04-0 ?JtytG - c+ ~:J-C -' 1324 TO 13604174709 -t.. t5' ...c '(<', ~. C5 \ IJ) , D & ~ ~ ~ - l' (' ~ ~ 'i~~.; 450Q miLL RcL Ou) 8 This work will require: Trenching in the RjW (total footage) 20 , Push or bore 2 inch PVC or EIP under roadway (total footage) d-~t) I V Push or bore 2 inch pVC or EIP under driveway (total' footage) Push or bore 2 inch pVC or alP under multiple driveways (total footage) D ** TOTAL ';;.-.::.~,i\;';.:~ '\\l' ,.. ,,',"",,; JUN 04 2004 12:39 FR TRAFTON B 253 471 1324 TO 13604174709 78'OB S. Tnlfton Tat:Qm8" W A 98409 , ",,"',," :..f......"...I.. '"1fal"'" -CacsimiI' . ", :e" .;~.:,::.;}~~. ',',\~...,' ; ." ,":....,' ':, Ie', ;~Ll:aJ.:~1:f1Pll' fr, , .,' To: City of Port Angeles Fax: 360-417-4709 From: Qwest Communications Date: 6/4/2004 Re: Pago.: CC: Dona ThaU! [J Urgent o For RevIew o Please Comment o PiGDe IUpIy o PIsase R8cyc1e " . . . " " . " . Notes: T. Funston. Permi. applications: Thank you, Dona Thaut 253.597.5136 ,<~\~M~/;< " ,- fY '" "'31::ir:::':.,>:,.,~:~.~;;?:.:' . ~ ~(I:. ' ,,':'< P.01/03 . :- .i:~.. ~~;::! t:"; ,.,,,1"" ,1", .>~fj~r~,;l ' "'.;ff,t!i. ~:];~:~~~ij , ; .';~;'?I~~' ""{ ';:';'~11~i~~~ .,\,[\'\'i~ ;',;:.:~~~~irA~~~ '",\,;'1;i!,,"r"~l& ':''''lII'\t;:,::r:'lf5 !,.1)r~~ ~,t.,~~ "', 'VI,'_,:\.~ ",';, r(i.~ 'ft. .{ti.~~~1 """"'11' ci~~ , " ~w'<U\,',j~ ;~I ." .'rl~~;;?i;pJ ,I.I'.1,f:;:.,.~'":l ~:I~~;li~ "'1~,,':~~e~'U:~ ' .~: J h~,~iP~~\i i';~" '(''''.''''".' ~t.-.~ :~, '):'~f~:~~~~ , ':I~"".l':1i<; . . -'-}:!:r~f~~i~f ,":T":':'~\'*I . ''\1'' "~' :[..t " .':}~:'~~~\7t~ , ",}.",t.~.,," . ",::,j:~J~~;J~ , ::. ,:'~~,~~':~;;ii~l '. " "~, :~;F~,,\\!,_ . :""'1/\:~,,'<7~.'i::j '. ,..... ~ .':l.,~};~~ .:'!</.,,,,!'"~1~ ';" . [;I.;';,"~;'cl .. .ti'!"'~l~"~&.~ .. :,X\~~~J:'i8: .,' 'r-\;"~~i;i! <;;~j~1:~ 'I. ,,' ~.,':l :;1 '~. :. ':'",. " JUN 04 2004 12:39 FR TRAFTON B 2534711324 TO 13604174709 P.02/03 ,~JI '" "~'t':.; "\' ;~i~.;~t~~ ,:', '~: '~~r;~~; "....,. ~~1 \I'~'i,;.! . :f'~!;'~:~~r:,' .,~" ;f"~f~~~ -.'- ,,,., , . b . "~,~ r.,;: APPLICATION is her~by m.de [0 the municipality of PORl' ANGE:!ES . to perform work as':,':i},"~)~~:~~ noted h~reon and ~s .,hown on anQched drawing: , . "">!\'~Z',\~i:) PLEASE:.. =e.e Al"CACtrE 'D ...5KE1i:~' wrs otfD3oWiY:f!!J!i . .,' ...., ~'.'" ,', ',. PI"'A' IrI....- fI ""l/JIlJIJ;n Wtl'n 1-.0 r\"QC'.J./l,._,lffl-v,.~~" _n'::."T.'t\jl l.l.UU- UJJ/.i..l(J.. d</~ [jL.X..-.- l)tyL ~<-;.rl L,A..l/..J..]4t:J"1JLI0~ "'r,;"",'~(:':,,',? L/S-cf1 2J. rXJJ.. truU ~d V\JrA).t Wt.U vUiJu~ ~ ' ',rqg, ~~~ ~~ ',~~ 1~ l...1..A.L.A ,......0 I) r \ . ,,1.. ""~V'l ~ Approved: ' ,'i;}~~~i , '," )~:: (,^..~tl~i' .l,.""'.,,f/_:tr"': . . '.-'["\'I '~tl..;.'>l;; , .'{~;)A:J,J,1r.",I,"~:;; , ~.,(i,.n'., ',' ,,1, , " .~'; ':~~I~~f~~ Sewer Depurtm8llt - Superintendent, ::ji",,;,!X~ The estimated time forcomple[ion of the above work Is ID 'DAVS A.PrElL n F"('e,pf.r:i}:~i~~~ '(Il.."'rr>'l,, . " "/:;"fr~,r'~Q o e (p - 4 - D '-I By i E~c..~L;~:n~Z;j;f Vf1on~' ~SJ- 5CJ1. Ol3(p Contractor X Owner';:>(i,;;r t'AX /}53. L/1/. /3()'4- OWE.5T IAii-N ;73S.\IJ flOO'''\ '.':!:~$.rl;~1; 7 ~ 13 . s . TR.4F- ToN .1f1(;(X1V:t~':~'~~ THE ABOVE APPLICATION IS HEREBY GRANTED SUBJECT TO APPI.lCANT'S: wtfqg:l}~~~~ ~::~~:;',:':,:~::::::::::~:;, "m. <h, wm' >rill "". ,.. wh<o " will flmo". ;~I~ Prosecuting the work with dilipnce. and with due. respecT to all propsrty ~ contracts. pe1"Son5ll'~ .' , . ." :.~!,I."'. righ ts and the in terests and l;onYenience of the P\lblic:;r:"~:,t.'~~ 'elf' <@/~ g)~ .- -- OI.JIOU.OWOFll<il Permit To Perform Work In Street Rillht-of- Water Department - Superintendent , (jj/UIli/; <j} /403 Saving the Municipality harmless from any and all damalle. which rnay acc:rue fO any penon or property because of this installation or The maintenance thereof; Complying with follOWing special conditions: t;,~~101 ~ City of E'ORr ANGELES Jv/l{Ad~tV4~ " ," . " ....j,. !,\:'~lt'?:',;l.\(; ":1 "{,.I:" . . '!t,. ,", ','it'" ,'~I .....,.'il:...;",.~ ,T:i~~~i Dale BY:::, ~~ ... .............JftoIU. ~ CITY OF PORT ANGELES DEP ARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION 321 EAST 5TH STREET, PORT ANGELES, WA 98362 Application Number pin number Property Address ASSESSOR PARCEL NUMBER: Application description Subdivision Name Property Use Property Zoning . . . Application valuation 04-00000220 Date .462420 4509 S OLD MILL RD 06-30-22-2-1-9000-0000- ELECTRICAL ONLY 3/22/04 RS9 RESDNTL SINGLE FAMILY o Owner Contractor GRAY, RANDY/JENNIFER 31 NELLO PLACE SEQUIM WA 98382 (360) 683-2318 SHAMP ELECTRICAL CONTRACTING PO BOX 383 PORT ANGELES WA 98362 (360) 452-1689 SHAMP ELECTRICAL 40.90 3/22/04 9/18/04 CONTRACTING Plan Check Fee Valuation .00 o ~ r~ ~'^ Permit Additional desc Sub Contractor Permit Fee Issue Date Expiration Date ELECTRICAL TEMPORARY SERVICE Qty Unit Charge Per 1.00 40.9000 ECH EL-TEMP SRV - 0-60 SRV FDR Extension 40.90 Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 40.90 40.90 .00 .00 Plan Check Total .00 .00 .00 .00 Grand Total 40.90 40.90 .00 .00 ~& ~ r' ~ ~ ~ ... Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last inspection. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construction. Signature of Contractor or Authorized Agent Date Signature of Owner (if owner is builder) Date T:IPLANNINGIFORMSI1 ] 02.15 [11/14/2003] BUILDING PERMIT INSPECTION RECORD CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICALINSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION. KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE. INSPECTION TYPE DATE ACCEPTED COMMENTS YES NO FOUNDATION: FOOTINGS WALLS FOUNDA T10N DRAINAGEIDOWN SPOUTS ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: # ROUGH-IN I PLUMBING UNDER FLOOR / SLAB ROUGH-IN WATER LINE (METER TO BLDG) GAS LINE BACK FLOW / WATER AIR SEAL WALLS CEILING I FRAMING JOISTS / GIRDERS SHEAR WALL/HOLD DOWNS WALLS / ROOF / CEILING DRYW ALL (INTERIOR BRACED PANEL ONLY) T-BAR INSULATION SLAB WALL / FLOOR / CEILING I MECHANICAL HEAT PUMP GAS LINE WOOD STOVE / PELLET / CHJMNEY HOOD / DUCTS PW UTILITIES / SITE WORK (Engineering Division) SEPARATE PERMIT #'5: WATERLINE / METER SEWER CONNECTION SANITARY STORM PLANNING DEPT. SEPARATE PERMIT #'5 SEPA: PARKING/LIGHTING ESA: LANDSCAPING SHORELINE: FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED YES NO ELECTRICAL - LIGHT DEPT. 417-4735 ELECTRICAL LIGHT DEPT CONSTRUCTION RW. / PW/ CONSTRUCTION - R.W. ENGINEERING 417-4807 PW / ENGINEERING FIRE 417-4653 FIRE DEPT. PLANNING DEPT. 417-4750 PLANNING DEPT. BUILDING 417-4815 BUILDING T:IPLANNINGIFORMSI1102.]5 [I III 4/2003] "......' /7 C" 5' Backflow Assembly Test Report City of Port Angeles Public Works and Utilities Department Water/Wastewater Collection Division Official Use Only Asscm,# S 3 J RC'l:cived NAME OF PREMISES: SERVICE ADDRESS: f( ///j/ n v , .{/ I , -I ,/ ;1/;1( // Iff <Ie::. f? ft1J{L , () f {,4/ /! T c.-if C; ,- , '>t/X't. --' ;/ '7 ,:::?~'? /7 I'l. y. )',/ Ct - 1 J " / LOCA nON OF DEVICE; ..;2 E A J- -;- ASSEMBLY: wit... k:- / /1/ 5'" /{' (/ /J j) /o/E -. / >/y , i C- )( Manufacturer Model Size / / /.' ,(;. /:/ Serial No. 5:'Y'? - ' L IS THIS AN APPROVED ASSEMBL Y? YES IB--'No 0 IS ASSEMBLY INST ALLEQ C;ORRECTL Y? YES 0 NO 0 l C ;.., '- DATE OF INSTALLATION /11/7 ,1/ ,..2/~S1JN1<NqW!NO- C I ,-'" '-. -~, --' REDUCED PRESSURE PRINCIPLE ASSEMBL Y RP D RPDA D " DC 1iJ--- DCDA D -.~... PVB D Air Gap D DOUBLE CHECK V AL V~SSEMBL'Y '.' SVB D AVB D to'" . , .il CHECK VALVE #1 CHECK VALVE #2 RELIEf VALVE PVB/SVB Initial Leaked D Leaked D Did Not Open D AIR INLET Held at 23si Closed Tight 0- Did Not Open D Test Held at ). C psi Opened at _ psi Opened at _ psi Repairs Cleaned 0 Cleaned D Cleaned D CHECK VALVE Leaked D Held at _psi Replaced D Replaced 0 Replaced D REPAIRS Cleaned D Details Replaced D 3 psi ButTer YES D NO 0 Final Closed Tight D AIR INLET Opened at _psi ') ") Held at;). (PSi CHECK VALVE Held at _psi Test Held at ~ psi Opened at ~ psi BACK PRESSURE NoD YESD AIR GAP INSPECTION: REQUIRED MINIMUM SEPARATION: YES D NO D .) ~/~-.., / TYPE Of HAZARD ,- COMMENTS Line Pressure ~psi - Y-/>'t: ( /? ,.1 - A/ Tev 71- - C- /,/ f- j ./ E // Held Backpressure YESD NO 0 ,) / / '/ #2 Shutoff Held YESD NO 0 Relief Valve Exercised YESD NO 0 DaterTime Tester Signature Cert,# Test Kit Passed Failed Initial ,- ~ Test 5"'/?~~j ;; /\ ,l;;~ i t' i ;<' /~/~ -, , 1../ . j i-' :yc- > '/ D 'l.-n-- . !/ Repairs 0 D final ('" . i /,_ (; f r f(-Je:: rff ~.:-,~/~, , Test , -, ,. I Y AA I frJ ;-v 1:' IlJ--'" 0 , ,,/ h -- , --, ,- WHITE - CUSTOMER COPY YELLOW - PURVEYOR COPY PINK - TESTER COpy