HomeMy WebLinkAboutPermit Backflow Test 2013-8-26 SPRINGFIELD 225 Fifth St
CITY OF SPRINGFIELD Springfield,OR 97477
p, Phone: 541-726-3753
OREGON Building / Commercial Permit Inspection Phone: 541-726-3769
Fax: 541-726-3676
PERMIT NO: 811-SPR201 3-01 91 4
www.springfieltlar.gov permilcenter @springfield-or.gov
PROJECT STATUS: Issued ISSUED: 08/26/2013 EXPIRES: 02/21/2014
STATUS DATE: 08/26/2013 APPLIED: 08/26/2013
SITE ADDRESS: 1630 12TH ST,Springfield,OR 97477 SCOPE: Backflow Device
ASSESOR'S PARCEL NO: 1703264110800 TYPE OF STRUCTURE: Commercial
PROJECT DESCRIPTION: Backflow for boiler
OWNER: OF SEVENTH DAY ADVENTISTS Phone Number:
ADDRESS: 605 SE 39TH AVE
PORTLAND OR 97214
OWNER: WEST ORE CONFERENCE ASSOC Phone Number:
ADDRESS: 605 SE 39TH AVE
PORTLAND OR 97214
CONTRACTOR INFORMATION
Contractor Type r Contractor Name Lic Type Lic No Lic Exp Phone
Plumbing Contractor LOREN DAVID WILSON COB 191757 09/01/2014 541-520-1572
INSPECTIONS REQUIRED
Inspections
•
3500 Rough Plumbing Rough Plumbing: Prior to cover and including required testing.
3620 Backflow Device Backflow Device: Prior to covering and provide a copy of the test report on site at the
time of inspection.
3999 Final Plumbing Final Plumbing: When all plumbing work is complete.
By signature, I state and agree,that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with the
Ordinances of the City of Springfield and the Laws of the State or Oregon pertaining to the work described herein, and that NO
OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further
certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. I further agree
to ensure that all required inspections are requested at the proper time,that each address is readable from the street,that the
permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during
constru tion.N„,
► I c b�ad��
• • •- o Contractor Signature Date
ATTENTION: Oregon law requires you to
follow rules adopted by the Oregon Utility a.:
Notification Center. Those rules are set forth NOTICE:
in OAR 952-001-0010 through OAR 952-001- THIS PERMIT SHALL EXPIRE W THE WORK
0090. You may obtain copies of the rules by AUTHORIZED UNDER THIS PERMIT IS NOT
calling the center. (Note` the telephc; o COMMENCED OR IS ABANDONED FOR
number for the Oregon Utility Notification
Center is 1-800-332-2344). ANY 180 DAY PERIOD.
Springfield Building Permit 8/26/2013 1:54:16PM Page 1 of 1
SPRINGFIELD CITY OF SPRINGFIELD
225 Fifth St
TRANSACTION RECEIPT Spnngfeld,OR97477
F`b'OREGON 541-726-3753
811-SPR2013-01914
www.springfieldocgov 1630 12TH ST permitcenter @spdngfield-or.gov
RECEIPT NO: 2013001876 RECORD NO:811SPR2013-01914 DATE:08/26/2013
')1 -Lol• jol ;°� rfi __ ,,f.,.,_i iti 'ACCOUNTICODE/TRANS CODE±T' :I . AMOUNT DUE:ttj
Backflow preventer 224-00000-425603 1005 21.00
Balance of Minimum Plumbing Permit Fees 224-00000-425603 1005 59.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 9.60
Technology fee(5%of permit total) 100-00000-425605 2099 4.00
TOTAL DUE: 93.60
•
>--P•YMENT TYPE :S.i'?P.AYOR A. - c�.S ritIgCONIMENTS y=�• . �r�' 'r�+ "-=AMOUNT PAID;;_ a ?�,ley:�.;j
Credit Card LOREN DAVID WILSON 93.60
036091
TOTAL PAID: 93.60
•
•
•
•
•
•
..:
Plumbing Permit Application
'..-:..*.DE ARTME NT USE.ONLy
-
8 nEFoNGe
Permit no.: 3//20/ 3 CY 7/V
HATIOntiratatilWattiOWAIAJaiiiiM3 allS'' a,%4
225 Fifth Street• Springfield,OR 97477 • PH(541)726-3753 • FAX(541)726-3689 .Date: 'Cai/z 6/(3
This permit is issued under OAR 918-780-0060. Permits are issued only to the person or contractor doing the work. Permits
expire if work is not started within 180 days of issuance or if work is suspended for 180 days.
LOCAL-J.GOVERNMENT -APPROVAL : e.:}:-. :,`±'_:,'1.:=JTEE tiSCHEDUILE7;%?7-'n*41f:::gC:r1:4;4 :::
Zoning approval verified? 0 Yes D No '113'etrilitioff.Vz-gri....;i1....,“,,,,Jii,i,„,5,,2:.:i: Qty;;:.,_!;,.Cost
.,,., : tElCo. al,
Sanitation approval verified? D Yes D No New residential
CATEGORY OF-.CONSTRUCTION 1 hathroomn kitchen(includes:first
100 feet of water/sewer lines, hose
E Residential 0 Government 0 Commercial bibs, ice maker, underfloor low-point $262.00 $
'JOB-.SITE INFORMATION .AND LOCATIONI 'lf drains and rain-drain packages)
Job site address: /4 ez) /Z-7467 2 bathrooms/1 kitchen $411.00 $
3 bathrooms/I kitchen $483.00 $
. City: -lie,74-/I State: OK ZIP:
Each additional bathroom(over 3) $104.50 $
Reference: ' Taxlot.: Each additional kitchen(over 1) $104.50 $
''ll71-7:?;: ll'7:‘•::'l1;'AD ESC R I PTICK Residential fire sprinklers(includes plan review)
/;44.41gat, go/- ho,/c-,-- 0 to 2,000 square feet $80.00 $
2,001 to 3,600 square feet $128.00 $
3,601 to 7,200 square feet $192.00 $
C ' 7,201 square feet and greatei $255.00 $
Name: Z--")&))(:_—)Q TA-t7)(1 V 400&..ikir/-9 i Manufactured dwelling or pre-fab(circle one)
Address: COOS SC, —3 1/61 Connections to building sewer and
$80.00 $
water supply
City: PoieTteSAJO State: ZIP:
Commercial,industrial,and dwellings other than one-or
Phone: - - Fax: - - two-family
E-mail: . Minimum fee $80.00 $
Each fixture $21.00 $
This installation is being made on residential or farm property
owned by me or a member of my immediate family, and is Miscellaneous fees
exempt from licensing requirements under OAR 918-695-0020. 100' storm,sewer,water line $83.50 $
Signature: Each fixture,appurtenance,and piping $21.00 $
',CONTRACIORI-INSTALFATION::::ir?t,tare,4 Storm water retention/detention facility $21.00 $
Business name: -2,CO Fitiptt/bi/de Irrigation systems $21.00 $
Piping or private storm drainage
Address: 3COE (j % ()+11 4.17;E-(---75 systems exceeding the first 100 feet $21.00 $
City: C_-__I--1,b-r--7 -6--: state )( ZIP: 97)/62 Specialty fixtures $21.00 $ -
Reinspection(no.of hrs.x fee per hr.) $80.00 $
Phone:54-5Z-ic-72 Fax: -
Special requested inspections(no.of
$80.00 $
E-mail: bafloolson.icy Essr-v, Q 9414//, e.014 hrs.x fee per hr.)
CCB license no.: if/754.111 BCD license no.: Each additional inspection: (1) $80.00 $
Plumbing license no 1,1yIeiti64-gas.tiitibiga-,5i1rith::;2 ;sits.,;-fti:s,i Minimum fee $
, i
Print name: 4.Zaga. 1 / SCA)
Signature: 6k(
c ) /•?sc Enter value of installation and equipment$ _.
Enter fee based on installation and equipment value. $
. .Etzliactial.:f*P:pniztovivisseyettnisioeam
(A) Enter subtotal of above fees
$
(Minimum Permit Fee$80.00)
(B)Investigative fee(equal to[A]) $
(C)Enter 12%surcharge(.12 x[A+B]) $
(D)Technology Fee(5%of[A]) $
TOTAL fees and surcharges(A through D): $ t31.6.------
440-2500-J(4/1/2013/COM)