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HomeMy WebLinkAboutPLIRR2018-2943 IJUL 3 U 1018 CCAIIeCQ k '%Q- 19 �. VPVIN�� cutie'l lo 'l l � ►�` CITY OF GRAPEVINE (CIRCLE ONE) MECHANICAL - ELECTRICAL - PLUMBING - IRRIGATION - FUEL GAS PERMIT APPLICATION PLEASE PRINT LEGIBLY-COMPLETE ENTIRE FORM PERMIT# ^ / BLDG.PERMIT# DATE: JOB ADDRESS: &ol V S �`� SUITE# DESCRIPTION OF WORK: `� PROPERTY OWNER: ;�- 'I ; e r C D CONTRACTING COMPANY: 1J ADDRESS: 30 r Je ADDRESS: CITYISTATEIZIP: l aS 5,A0 CITYISTATEIZIP: f PHONE NUMBER: \ PHONE NUMBER: l_7a--7a3-0^0� TYPE OF OCCUPANCY BUILDING AREA PERMIT FEES /AMOUNT DUE SQ FT EACH TRADE I. R-3 1 - 749 $ 33.25 SINGLE FAMILY, DUPLEX 750- 1,199 $ 49.88 TOWNHOUSE, 1,200- 1,500 $ 63.18 NEW CONSTRUCTION & 1,501 - 1,750 $ 76.48 ADDITIONS (PER UNIT) 1,751 - 2,000 $ 83.13 2,001 - 2,250 $ 89.78 TOTAL SQ. FOOT UNDER 2,251 - 3,000 $ 96.43 ROOF 3,001 - 3,500 $ 103.08 3,501 - 4,000 $ 109.73 $ 4,001 + $ 120.37 EACH TRADE II. A, E, I, R-1 1 - 500 $ 37.00 HOTELS,APARTMENTS, 501-100,000 $ 17.50+.035 PER DRINKING/DINING, 100,001 -500,000 $ 3,500.00+.03 SQUARE EDUCATIONAL,ASSEMBLY, 500,001 + $15,000.00+.02 FOOT $ INSTITUTIONAL EACH TRADE III. B, F, H, M. S, U OFFICE, RETAIL, WHOLESALE, 1 - 500 $ 37.00 GARAGES, FACTORIES, 501 - 50,000 $ 32.00+ .01 PER WORKSHOPS, SERVICE 50,001- 100,000 $ 182.00+ .007 SQUARE STATIONS, WAREHOUSE 100,001+ $ 582.00+ .003 1 FOOT $ CONTRACT EACH TRADE IV. ANY OCCUPANCY GROUP VALUATION OF WORK FINISH-OUTS, SHELL COMPLETIONS, 0- 500 $ 37.00 ALTERATIONS OR 501- 1,500 $ 45.00 STAND ALONE PERMITS 1,501- 3,000 $ 67.00 3,001- 5,000 $ 72.00 CONTRACT VALUATION OF WORK: 5,001- 50,000 $ 27.00+.009 50,001- 100,000 $ 127.00+.007 PER $ 100,001-500,000 $ 327.00+.005 DOLLAR $ 500,001+ $ 1,327.00+ .003 IVALUATION V. MISCELLANEOUS EACH TRADE UZRIGATION SYSTEM $ 37.00 MOBILE HOME SERVICE $ 37.00 TEMPORARY POLE SERVICE $ 37.00 SWIMMING POOLS $ 37.00 SIGN ELECTRIC $ 37.00 $ 5 UZ� S C\Users�batle\AppData\LocalWicrosafi\windows\Temporary IntemetFles\Content.Outlook\G88E6GOFWEP APPLICATION 4-11.doc PLAN SUBMITTAL: WHEN PLANS ARE REQUIRED BY CODES, ORDINANCES, OR AS DETERMINED BY THE BUILDING OFFICIAL, THREE (3) SETS OF PLANS SHALL BE SUBMITTED IN HARD COPY FORMAT. ENGINEER SEALED PLANS AND CALCULATIONS SHALL BE SUBMITTED AS REQUIRED BY CODES, ORDINANCES OR WHERE OTHERWISE REQUIRED BY STATE LAW. OTHER INSPECTIONS AND FEES: • INSPECTIONS OUTSIDE NORMAL BUSINESS HOURS (2HR MINIMUM)............................................-S42.00/HOUR* • REINSPECTION FEES.......................................---...................................................._........... . $42.00 • PERMITS FOR WHICH NO FEE IS SPECIFICALLY INDICATED........................................................... $37,00 • INSPECTIONS FOR WHICH NO FEE IS SPECIFICALLY INDICATED(1/2 HOUR MINIMUM),.................. S42.00/HOUR ADDITIONAL PLAN REVIEW REQUIRED BY CHANGES, ADDITIONS, OR REVISIONS TO APPROVEDPLANS............. .._................_..................................................._............._..........$42.00/HOUR BUILDING PERMIT FEES FOR THE GRAPEVINE-COLLEYVILLE INDEPENDENT SCHOOL DISTRICT SHALL BE 25%OF THE FEES ESTABLISHED IN THIS TABLE • FOR USE OF OUTSIDE CONSULTANTS FOR PLAN CHECKING AND INSPECTIONS, OR BOTH.........ACTUAL COSTS** I HEREBY CERTIFY THAT THE FOREGOING IS CORRECT TO THE BEST OF MY KNOWLEDGE AND ALL WORK WILL BE PERFORMED ACCORDING TO THE DOCUMENTS APPROVED BY THE BUILDING DEPARTMENT AND IN COMPLIANCE WITH THE CITY OF GRAPEVINE CODES REGULATING CONSTRUCTION. IT IS UNDERSTOOD THAT THE ISSUANCE OF THIS PERMIT DOES NOT GRANT OR AUTHORIZE ANY VIOLATION OF ANY CODE OR ORDINANCE OF THE CITY OF GRAPEVINE. I FURTHER CERTIFY THAT ALL WORK THAT IS REQUIRED TO COMPLY WITH ANY FEDERAL, STATE, AND / OR LOCAL LAW REGARDING ENERGY CONSERVATION WILL BE PERFORMED IN ACCORDANCE WITH THOSE LAWS, AND THAT VERIFICATION OF ENERGY CODE COMPLIANCE SHALL BE SUBMITTED TO THE CITY UPON REQUEST. _ bus-b'n fAdOms SIGN URE OF CONTRACTOR OR AUTHORIZED AGENT PRINTED NAME (OR HOMEOWNER FOR HOMEOWNERS PERMITS) PHONE#: ("l I a--7 •� - y l D A EMAIL: - ' , *OR THE TOTAL HOURLY COST TO THE JURISDICTION WHICHEVER IS GREATER. **ACTUAL COSTS INCLUDE ADMINISTRATIVE AND OVERHEAD COSTS. Development Services Department,Building Inspections The City of Grapevine * P.O. Box 95104 *Grapevine,Texas 76099 *(817)410-3165 Fax(817)410-3012 *www.grapevinetexas.gov C\Users\sbadeWppOata\Loral\Microsoft\Windows\Temporary Internet Files\ContentOutloohG8DE8GQF\MEP APPLICATION 4-1 Unc CITY OF GRAPEVINE jB4?079 BACKROW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: GRAPEVINE ANNUAL TEST IRRIGATION y PWS I.D.# 2200013 OTHER NAME OF BUSINESS WHERE DEVICE IS LOCATED: I'14yp ADDRESS OF SITE SERVICED: 3co1 ko, E Woods Ave PLUMBING PERMIT IF APPLICABLE: # I S- 2q 4 3 TESTER LICENSE NUMBER: S P 1 25-93 EXPIRES: IU- Z$ - -Z-1 DATE OF LAST TEST GAUGE CALIBRATION: 10 - I$- 1 C6 THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY TCEQ REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS. TYPE OF ASSEMBLY REDUCED PRESSURE PRINCIPLE _ PRESSURE VACUUM BREAKER DOUBLE CHECK —ATMOSPHERE VACUUM BREAKER MANUFACTURER: Gov,6,,O�C, SIZE: --)-`r MODEL: SERIAL NUMBER: R k 9 9 PHYSICAL LOCATION OF METER: o"a- So -ti 51-4 Aew Vv�uS�or. v REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER DOUBLE CHECK VALVE ASSEMBLY AIR INLET CHECK VALVE 1ST CHECK 2ND CHECK RELIEF VALVE Open at psid psid DC osed Ti osed Tight Opened at Initial _RP 2 (o psid Did not open Leaked Test psid Leaked Leaked Repair Materials Used Test DC-Closed Tight Opened at Opened at After Closed Tight psid Repair RP_ psid _psid _psid The above is certified to be true. TESTERS FIRM NAME: C rn2 na ADDRESS: -Aq3Z S) CITY/STATE/ZIP: DATE: 4,7 — PHONE NUMBER: PRINTNAME: SIGNATURE: DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT(817) 410-3010 O TORMS1DS IRRIGATION INI'MBACKMW TEST REPORT.d.a Revised'.1,06,P110 CITY OF GRAPEVINE /&/V18Z�1,9 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: GRAPEVINE ANNUAL TEST PWS I.D.# 2200013 IRRIGATION t/ OTHER NAME OF BUSINESS WHERE DEVICE IS LOCATED: IV1�.5)0 '`9 r�+�ha✓ �T�Ilnw+ ADDRESS OF SITE SERVICED: Soul 1✓awood-, I4yr. PLUMBING PERMIT IF APPLICABLE: # SS 2q�J 3 TESTER LICENSE NUMBER: I�PI Z5 C, EXPIRES: 10 DATE OF LAST TEST GAUGE CALIBRATION: to- 1 4L - 142) THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY TCEQ REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS. TYPE OF ASSEMBLY REDUCED PRESSURE PRINCIPLE _PRESSURE VACUUM BREAKER DOUBLE CHECK —ATMOSPHERE VACUUM BREAKER MANUFACTURER: can. W-Co SIZE: au � [ p MODEL: L(v/O$9q i- SERIAL NUMBER: C� T2 `7 O PHYSICAL LOCATION OF METER: t srotz Sft(a w,."sit,ro,j A, REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER DOUBLE CHECK VALVE ASSEMBLY AIR INLET CHECK VALVE 1"CHECK 2No CHECK RELIEF VALVE DC osed Tia osed Tigh Open at psid _psid Initial _RP 2•K psid Opened at Did not open Leaked Test psid Leaked Leaked Repair Materials Used Test DC-Closed Tight Opened at Opened at After Closed Tight _psid Repair RP_ psid _psid psid The above is certified to be true. TESTERS FIRM NAME: onL\ �, ADDRESS: 313214ey,� ;�1 �h CITY/STATE/ZIP: DATE: (O PHONE NUMBER: ybC1 ZS"$ 7 720 PRINT NAME: ) ntaa1(s�Ic xC L�. SIGNATUR DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT(817) 410-3010 0 YORMSIDS IRRIGATION INFOIBACKFIAW TEST REPORT.doc Reis d:1/06,2/10 FN�d 33HS LI••-al-Y• / y �v/ lad �Ntly.. 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PERMIT # DA: i JOB ADDRESS: 30c) l I fR E: V CnAs Avp-- SUITE # �1 DESCRIPTION OF WORK: L'otivk5 C c.,pe- Ct_a'ICi f cn PROPERTY OWNER: J� � ��� e �7T����t��,J� CONTRACTING COMPANY.tE,, ADDRESS: 9051 IfQ �C�O � G ADDRESS: V � � E M o 1 ✓L S\Ye.Q- - CITY/STATE/ZIP: PHONE NUMBER: TYPE OF OCCUPANCY I. R-3 SINGLE FAMILY, DUPLEX TOWNHOUSE, NEW CONSTRUCTION & ADDITIONS (PER UNIT) TOTAL SQ. FOOT UNDER ROOF II. A, E, I, R-1 HOTELS, APARTMENTS, DRINKING/DINING, EDUCATIONAL, ASSEMBLY INSTITUTIONAL `m Ibo5-1 III. B,F,H,M,S,U OFFICE, RETAIL, WHOLESALE, GARAGES, FACTORIES, WORKSHOPS, SERVICE STATIONS, WAREHOUSE IV. ANY OCCUPANCY GROUP FINISH -OUTS, SHELL COMPLETIONS, ALTERATIONS OR STAND ALONE PERMITS CONTRACT VALUATION OF WORK: S PAPI6YsI:l11A_\1Ixil11by IRRIGATION SYSTEMS MOBILE HOME SERVICE TEMPORARY POLE SERVICE SWIMMING POOLS SIGN ELECTRIC BUILDING AREA (SO FT) CITY/STATE/ZIP: A1 PHONE NUMBER. �1 Z- -7 Z 3 - 0'7 o-L PERMIT FEES AMOUNT DUE EACH TRADE 1 - 749 $ 3325 750 - 1,199 $ 49.88 1,200- 1,500 $ 63.18 1,501 - 1,750 $ 76.48 1,751 - 2,000 $ 83.13 2,001 - 2,250 $ 89.78 2,251 - 3,000 $ 96.43 3,001 - 3,500 $ 103.08 3,501 - 4,000 $ 109.73 $ 4,001 + $ 120.37 EACH TRADE 1 - 500 $ 37.00 501 - 100,000 $ 17.50+.035 PER f 100,001 - 500,000 $ 3,500 00+,03 SQUARE 500,001 + $15,000.00+.02 FOOT $ EACH TRADE 1 - 500 $ 37.00 501- 50,000 $ 32.00+.01 PER f 50,001- 100,000 $ 182.00+.007 SQUARE 100,001+ $ 58200+.003 FOOT $ �ONTRACT EACH TRADE VALUATION OF WORK 0- 500 $ 37.00 501- 1,500 $ 45.00 1,501- 3,000 $ 57.00 3,001- 5,000 $ 72.00 5,001- 50,000 $ 27.00+.009 50,001-100,000 $ 127.00+.007 PER 100,001-500,000 $ 327.00+.005 DOLLAR $ 500,001+ $ 1,327.00+.003 VALUATION EACH TRADE 37.0 $ 37.00 $ 37.00 $ 37.00 $ 37.00 $ C.\Users\sbaftelAppOata\Local\Microsoft\Windows\Temporary Internet Files\Content Out ook\G80E6GORMEP APPLICATION 4-11 doc PLAN SUBMITTAL: WHEN PLANS ARE REQUIRED BY CODES, ORDINANCES, OR AS DETERMINED BY THE BUILDING OFFICIAL, THREE (3) SETS OF PLANS SHALL BE SUBMITTED IN HARD COPY FORMAT. ENGINEER SEALED PLANS AND CALCULATIONS SHALL BE SUBMITTED AS REQUIRED BY CODES, ORDINANCES OR WHERE OTHERWISE REQUIRED BY STATE LAW. OTHER INSPECTIONS AND FEES: • INSPECTIONS OUTSIDE NORMAL BUSINESS HOURS (2HR MINIMUM) ............. ....... .......................... $42.00/HOUR" REINSPECTION FEES....................................................................... ................. ................... $42.00 • PERMITS FOR WHICH NO FEE IS SPECIFICALLY INDICATED....................................................... $37.00 • INSPECTIONS FOR WHICH NO FEE IS SPECIFICALLY INDICATED (1/2 HOUR MINIMUM) ...... .............. $42.00/HOUR • ADDITIONAL PLAN REVIEW REQUIRED BY CHANGES, ADDITIONS, OR REVISIONS TO APPROVEDPLANS .................... ........................................... ........... ............ ................. ........... $42.00/HOUR • BUILDING PERMIT FEES FOR THE GRAPEVINE-COLLEYVILLE INDEPENDENT SCHOOL DISTRICT SHALL BE 25% OF THE FEES ESTABLISHED IN THIS TABLE • FOR USE OF OUTSIDE CONSULTANTS FOR PLAN CHECKING AND INSPECTIONS, OR BOTH......... ACTUAL COSTS** I HEREBY CERTIFY THAT THE FOREGOING IS CORRECT TO THE BEST OF MY KNOWLEDGE AND ALL WORK WILL BE PERFORMED ACCORDING TO THE DOCUMENTS APPROVED BY THE BUILDING DEPARTMENT AND IN COMPLIANCE WITH THE CITY OF GRAPEVINE CODES REGULATING CONSTRUCTION. IT IS UNDERSTOOD THAT THE ISSUANCE OF THIS PERMIT DOES NOT GRANT OR AUTHORIZE ANY VIOLATION OF ANY CODE OR ORDINANCE OF THE CITY OF GRAPEVINE. I FURTHER CERTIFY THAT ALL WORK THAT IS REQUIRED TO COMPLY WITH ANY FEDERAL, STATE, AND / OR LOCAL LAW REGARDING ENERGY CONSERVATION WILL BE PERFORMED IN ACCORDANCE WITH THOSE LAWS, AND THAT VERIFICATION OF ENERGY CODE COMPLIANCE SHALL BE SUBMITTED TO THE CITY UPON REQUEST. SIG ATM CONTRACTOR OR AUTHORIZED AGENT PRINTED NAME (O HOMEOWNER FOR HOMEOWNERS PERMITS) PHONE# - I?( -- I ZS-0-702- EMAIL: (> - *OR THE TOTAL HOURLY COST TO THE JURISDICTION WHICHEVER IS GREATER. **ACTUAL COSTS INCLUDE ADMINISTRATIVE AND OVERHEAD COSTS. Development Services Department, Building Inspections The City of Grapevine * P.O. Box 95104 * Grapevine, Texas 76099 * (817) 410-3165 Fax (817) 410-3012 * www.grapevinetexas.gov C \Users`sbattet ppOata\Loo hMicrosoft"Nindows\Temporary Internet Res\Con tent. OutlooktG80EeGOF1MEP APPLICATION 4-11 doc City of Grapevine P.O. Box 95104 Grapevine, TX 76099 (817) 410-3165 Voice (817) 410-3012 Fax CONTRACTOR Earthtones Design [HOLD] State ID # L10009816 P.O. Box 968 PLUMBING - IRRIGATION PERMIT Issue Date: January 14, 2021 PROJECT DESCRIPTION: Install Commercial Irrigation System "Mustang Panther Stadium" [EXPIRED] TURN IN TCEO t LETTER OF COMPLIANCE & FINAL [SCANNED IN LF] PROJECT # (817) 410.3010 www.mygov.us PLIRR-18-2943 inspections Permits LOCATION TENANT LEGAL 3001 Ira E Woods Ave. Mustang Panther Stadium Education Center Addition No Grapevine, TX 76051 3 Blk 1 Lot la Per Plat A460 Midlothian, TX 76065 (972)723-0702 Phone OWNER Isd Grapevine Colleyville 3051 Ira Woods Ave E Grapevine, TX 76051-3817 AVAILABLE INSPECTIONS Letter of Compliance (Irrigation) (required) i, TCEQ Backflow Certification Submit (required) Backflow Device Inspection (required) MISC. Irrigation Inspection (required) . Plumbing Customer Sevice Inspection (required) . Plumbing Final (required) INFORMATION County Tarrant Square Footage FEES TOTAL = $ 111.00 Plumbing Miscellaneous Fee $ 74.00 Plumbing Miscellaneous Fee $ 37.00 PAYMENTS TOTAL = $ 111.00 Earthtones Design [HOLD] (Michael Crocker) Other on 0713012018 Note: CC4578 ($37.00) Earthtones Design [HOLD] (Michael Crocker) Other on 0111412021 Note: CC1230 ($74.00) NOTICES ALL work must be done in compliance with the 2006 INTERNATIONAL PLUMBING CODE. PLAN SUBMITTAL: WHEN PLANS ARE REQUIRED BY CODES, ORDINANCES, OR AS DETERMINED BY THE BUILDING OFFICIAL, THREE (3) SETS OF PLANS SHALL BE SUBMITTED IN HARD COPY FORMAT. ENGINEER SEALED PLANS AND CALCULATIONS SHALL BE SUBMITTED AS REQUIRED BY CODES, ORDINANCES OR WHERE OTHERWISE REQUIRED BY STATE LAW. READ AND SIGN I HEREBY CERTIFY THAT THE FOREGOING IS CORRECT TO THE BEST OF MY KNOWLEDGE AND ALL WORK WILL BE PERFORMED ACCORDING TO THE DOCUMENTS APPROVED BY THE BUILDING DEPARTMENT AND IN COMPLIANCE WITH THE CITY OF GRAPEVINE CODES REGULATING CONSTRUCTION. IT IS UNDERSTOOD THAT THE ISSUANCE OF THIS PERMIT DOES NOT GRANT OR AUTHORIZE ANY VIOLATION OF ANY CODE OR ORDINANCE OF THE CITY OF GRAPEVINE. FURTHER CERTIFY THAT ALL WORK THAT IS REQUIRED TO COMPLY WITH ANY FEDERAL, STATE, AND / OR LOCAL LAW REGARDING ENERGY CONSERVATION WILL BE PERFORMED IN ACCORDANCE WITH THOSE LAWS, AND THAT VERIFICATION OF ENERGY CODE COMPLIANCE SHALL FLE3 2,5-2021 GUARANTEE FOR PLANTING IRRIGATION SYSTEM We hereby guarantee that the planting irrigation system we have furnished and installed is free from defects in materials and workmanship, and the work has been completed in accordance with the drawings and specifications, ordinary wear and tear and unusual abuse, or neglect excepted. The Irrigation system has been installed in accordance with all applicable State and Local laws, ordinances, rules, regulations and orders. I have tested the system and determined that it has been installed according to the irrigation plan and is properly adjusted for the most efficient application of water at this time. We agree to repair or replace any defects in material or workmanship which may develop to repair or replace any damage resulting from the repairing or replacing of such defects at no additional cost to the Owner. We shall make such repairs or replacements within a reasonable time, as determined by the Owner, after receipt of written notice. In the event of our failure to make such repairs or replacement within a reasonable time after receipt of written notice from the Owner, we authorize the Owner to proceed to have said repairs or replacements made at our expense and we will pay the costs and charges therefore upon demand. PROJECT: 1 '2u�A�Si t1al��. ' �f ")Tu.�✓�n LOCATION: I jv� ( Z�4 E lA/ald5 COMPANY: 2�fi11�5 �tSiQlr� ADDRESS: Jl$i r(G7Vl�.iCcn/ rUd PHONE: ( LL�) Q4ll — (0-71ro DATE OF ACCEPTANCE: L / r / I- — BLAKE A. STARNES ..................... 24693 i Toya-.!`,.m.+,;cc;.,n cza En.wii;$Rll.al;r? BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping *pumoses: I NAME OF PWS: Grapevine, Texas _ PWS ID#: #2200013 PWS MAILING ADDRESS 501 Shady Brood-Dr—Grapevine;Tz -I[�1— PWS CONTACT PERSON Backflow Coordinator. Jimmy Brock a ' ADDRESS OF SERVICE: &? o I 1 k y+ s-_1A,a,-,. w s The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations r and is certified to be operating within acceptable parameters. TYPE OF BACKFLOW PREVENTION ASSEMBLY (BPA): ❑; Reduced Pressure Principle (RPBA) ❑ Reduced Pressure Principle -Detector (RPBA-D) Type II'❑ Double Check Valve (DCVA) ❑ Double Check -Detector (DCVA-D) Type II ❑I ❑ Pressure Vacuum Breaker (PVB) ❑' Spill -Resistant Pressure Vacuum Breaker (SVB) tvianufacturer: iVlain: Gtk b Vat e 0 Bypass:: i size: % main: Bypass: f YP Model Number: I Main: 4 LI I b 9 T-k Bypass:' BPA Location: 9c) X ctt VLv.W Serial Number: Main; tL rA ej r, Bypass; I BPA Serves: I 1 N V s q'X+ Cs r J Reason for test: I New ❑ Existing .1 Replacement ❑ Old Model/Serial #; 1 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? uYes I ❑ No Is the assamhly installed on a non -potable water supply (auxiliary)? n YAs TEST RESULT _,.., Type II I PASS FAIL ❑ Test �2 3v Repairs and Materials Used** Reduced Pressure Principle Assembly (RPBA) Assembly PVB & SVB DCVA 0 Relief Valve Bypass Check Air inlet II Check Valve V Check Held at2L�, psid Closed Tight Z Leaked ❑ Main: iieia at _ psid Closed Tight ❑. 2"d Check*** Held at' 2'`ipsid iIOpened at (Held at psid, Opened at psid I Held at ' Closed Tight ',�, psid Closed Tight ❑ Did not open ❑ Pstd Did noY Did it full u en IlLeaked❑I Leaked ❑ Leaked ❑ Y P open ',❑ at _ t riew at _ psiu ll Opened la _ psiu held at Closed psid Tight Ell i nrid c check:- _ numeric reautng required foi DCVA A lint Differential pressure gauge used: Potable: ®! I Non -Potable: ❑ Make/Model: Wilkins tg 5 SM1 09190350 _Date tested for accuracy Remarks: - trt/; beF+ cofir t(T-r Q✓'tvv 7b 7--e!; y ile vNit -(!r at psid -d Tight ;❑ Cottipany Naiite: I AAA Baekflow, LLC Liceiisdd T ester Natiie (Print/Type): Company Address: po box 173453 Licensed Tester Name (Signature): I hris DeFrancis Company Phone #: BPAT License # �p SJ� I $ 817-975-650o I License Expiration Date: I 3-23-21 The above is certified to be true at the time of testing. * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS 130 TAC s290 d/_,(A)1 ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS 12-29-20 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT The following form mukt be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping *purposes: { NAME OF PWS: i Grapevine, Texas FS.0 1 PWS ID#: #2200013 _ _ 6 PWS MAILING ADDRESS: 501 Shady Brood Dr. Grapevine, Tx. 76051 PWS CONTACT PERSON: Backflow Coordinator Jimmy Brock { ADDRESS OF SERVICE: Oj 0 () I 1 iL. A- E- uk' oc) fy 5 The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF BACKFLOW PREVENTION ASSEMBLY (BPA): ❑ Reduced Pressure Principle (RPBA) ❑ Reduced Pressure Principle -Detector (RPBA-D) Type II ❑i Double Check Valve (DCVA) ❑ Double Check -Detector (DCVA-D) Type B'❑, ❑ Pressure Vacuum Breaker (PVB) ❑ Spill -Resistant Pressure Vacuum Breaker (SVB) j Ivianufaciurer: 1viairr. (!'0" rrt t D Bypass - - Size: 2 gain. ; Bypass:;: Model Number. Main: l{ lQ �)G+OI Bypass:';' I BPA location: 19 y (z,f plaHV { Serial Number: Main:!&- Z gi Bypass: - I BPA Serves: `', ' ,1-W rlyy k- --d Reason for test: I New ❑ I Existing X i Replacement ❑; Old Model/Serial # Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Is the assembly installed on a non- notable water supply (auxiliarv)? TEST RESULT Type II Reduced Pressure Principle Assembly (RPBA) Assembly PASS E I DCVA 01Yes ElNo f t Yes J jl Ain PVB & SVB Relief Valve Bypass Check Air inlet FAIL ❑ I 1" Check 2n' Check*** ;Initial Test IlHeld at -' i psid Held at'2psid (Opened at _ Held at ^ psidNOpened aC—i psid Date: i7o-Vf 'Closed Tight �Time: Closed Tight j I Pstd Did not Closed Tight ❑ Did not open ❑ u en p f�nioFi�' Leaked ❑ Leaked Cl ❑ Leaked ❑ �Diditfull y open �� � (Yes ❑ /No ❑,) Renairc and r Materials Used** Tesi.T After Re air (Date: Time: Bypass: Held at psid Closed Tight ❑ at psid ed Tight ❑ at _ 11 seta at 9 Check V aive Held at psid Leaked ❑ n psid !I ileid at , 2 rdGuccn. imiueric reading reyiiircd rvr DCVA A only _ Differential pressure gauge used: Potable: ®j Non -Potable. ;❑ Make/Model:- Wilkins tg 5 SN-'A 09190350 LDate tested for accuracy : ! j 12-29-20 Remarks: (.52W T e _L -WiF UHF Py' 'a'' lv 'tf'Sfi V74 ! - Com an Name: { Licensed Tester Name P Y I AAA Backflow, LLC ' hris DeFrancis (Print/Tyoe): Company Address: I po box 173453 Licensed Tester Name (Signature): I Company Phone #: BPAT License # j BP 0012038 817-975-6500 { License Expiration Date: { 3-23-21 The above is certified to be true at the time of testing. * TEST RECORDS MUST BE KM FOR AT LEAST THREE YEARS r30 TAC §290.46(B)I ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS