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25A-185 (64) m 0 m r O O \W S 3 1J� � G r � o r cc) � m rr– D D C-) 6� O F- rte- m O cfl �- �o O <m _c. m 0 Zc _ `- �y v c- n v ao N y�n� O m N Dou3 = Z m F v u� m m XW 0 Dnm `T' tr n ��o r° r V cD � C7 O CD 70 z xm zW r2 U) -i D s z�m N= �Z ,� �Z N N C7 � 1 CITY OF NORTHAMPTON DEPARTMENT OF PUBLIC WORKS nor `9g7 DIVISION OF WATER SUPPLY APPLICATION FOR INSTALLATION °"b BACKFLOW PREVENTION DEVICE DESIGN DATA SHEET I. Owner's Name Cots,` co© cx_ _ y Address Lis Zh �S�c1u� t�Ci J2 (1 ot� ,r,,•P �� M� 61c)(00 Telephone No. Cti In 5ga- Ccs IS ' II. FACILITY (a) Name CoGc,-- co�c,,, (b) Address 4 S Zr Or 1(loc�hv M {o� (c) Contact Person/Agent `Te-" &o sell (d) Telephone No. of facility contact person 413) SSa- (0513 (e) r New Facility Existing Facility General description for the need of the i tallation of a backflow device Pco�ea Po��lQ wa�et- Sfe d wafer hose &eL III. DEVICE DATA (a) Manufacturer Name Wcx.i{S Model No. 901 a+ (b) RPBP ✓ or Double Cho Valves Size V-11, (c) Hot or Cold Water Unit Got By-pass Arrangement: Yes or No (d) Exact Location of Device Lo � C)C- C (e) Water Usage Down Stream of Device-'-' d- Sig+ 0"-N (f) Gate Valve Ball Valve 6-'- Butterfly Valve IV, PLANS AND SPARE PARTS REQUIRED 1. The installation contractor is responsible for supplying a spare rubber parts kit for each device 2. A fully labeled, detailed schematic of the potable and non-potable water piping immediately surrounding the backflow prevention device installation showing: (a.) height above floor of the device (b.) distance from wall of the device (c.) type of chemical(s) used (if any) and the type of equipment upstream, and downstream of the device Please note: The schematic drawing must be at least 8 1/2 by 11 inches with the following information in the completed title block. Submitted by: t'n c)vc6^� r­ Plumber's Signature: Plumber's License 1f: 199 S to / Owner/Agent Sig ature: Date: l/I25 7 All information listed above must be included on schematic drawing In addition, a fee of $65.00, made payable to the City of Northampton for each device application must be submitted to the D P W before any application will be processed. A permit from the plumbing inspector may be necessary for the installation of these devices. Approvals or denials of this application will be sent directly to the owner. c:\wafne ft'ton\form ImMstaAm.t