HomeMy WebLinkAboutPermit Backflow Test 2013-8-29 SPRINGFIELD 225 Fifth St
• CITY OF SPRINGFIELD Springfield,OR97477
Phone: 541-726-3753
OREGON Building I Commercial Permit Inspection Phone:541-726-3769
Fax: 541-726-3676
PERMIT NO: 811-SPR2013-01971
www.spnngfield-or.gov permitcenter @springfield-or.gov .
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PROJECT STATUS: Issued ISSUED: 08/29/2013 ' EXPIRES: 02/24/2014
STATUS DATE: 08/29/2013 APPLIED: 08/29/2013
SITE ADDRESS: 3100 PIERCE PKWY,Springfield,OR 97477 SCOPE: Backflow Device
ASSESOR'S PARCEL NO: 1702300001000 TYPE OF STRUCTURE: Commercial
PROJECT DESCRIPTION: BackFlow Permit .
OWNER: STATE OF OREGON MILITARY DEPARTMENT Phone Number:
ADDRESS: PO BOX 14350 •
SALEM OR 97309
CONTRACTOR INFORMATION
Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone
Plumbing Contractor WILLIAM WARREN KINGSLEY II CCB 126075 01/11/2015 541-937-2892
Plumbing Contractor BROTHERS PLUMBING INC CCB 198624 12/31/2014 541-937-2994
INSPECTIONS REQUIRED
Inspections
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
construction.
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n/4-��,04-- f-27—/y
Owner or Contractor Signature Date •
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Oregon law requires you to
NOTICE: ATTENTION: Oreg the Oregon Utility
THIS PERMIT UNDER EXPIRE IF THE WORK follow rules adopted by
Notification Center. Those rules AR g52f001-
iJTHORIZED UNDER THIS PERMIT IS NOT in OAR 952-001-0010thrcug
riMMENCED OR IS ABANDONED FOR
0090. You may obtain copies of the rules by
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RO DAY PERIOD.
calling the center. (Note: the telephone
number Cienterthe
iss 1e8D0.332 2344). dt o Utility
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. Springfield Building Permit 8/29/2013 1:34:56PM Page 1 of 1
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SPRINGFIELD -- CITY OF SPRINGFIELD
225 Fifth St
OR E oN TRANSACTION RECEIPT Springfeld,Oft97477
541-726-3753
811-SPR2013-01971
www.springfield-or.gov 3100 PIERCE PKWY permilcenter@spdngfield-ar.gov
RECEIPT NO: 2013001923 RECORD NO:811 SPR2013-01971 DATE:08/29/2013
{efzxA:�l' ojyl l<`+rj-u_7±S_blaisif_ AZVLfl=-LCS�::L. ,.?:ACCOUNT COD ': : • o o _1_=-;4,��.;:_'AMOUNT o
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
PAYMENTer1YPE--_ _PAYOR cgSr+lER iA SoR .COMMENTS AMO_VNTWPAID,
Credit Card WILLIAM WARREN KINGSLEY II 93.60
01453C
TOTAL PAID: 93.60
Plumbing Permit Application NLY "
SPNINGFIELG �7 (A'
°itfMsi-x .^ yiascal .:. ,.di ^� .'Q"v _ lg, N ! t i' 8 I GEJ[' 3 ��_(
G'sIT.�'GF,SPR11s-GFitura LTGD_N , t 17 '°'--� 4 Permit no 7l
225 Fifth Street• Springfield,OR 97477 • PH(541)726-3753 • FAX(541)726-3689 Date: g/79// 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 ;GOVERNMENT APPROVAL ', .., FEE' SCHEDULE r-
Zoning approval verified? ❑ Yes ;Cost Total
❑No Oescnptlon �� QtY ye ' ` : cost `.
Sanitation approval verified? ❑ Yes ❑No New residential
CATEGORY.`OF CONSTRUCTION 1 bathroom/1 kitchen(includes:first
❑Residential ❑ Government ❑ Commercial
100 feet of water/sewer lines, hose $262.00 $
, bibs, ice maker, underfloor low point
'JOB SITE-INFORMATION`.ANDDJ/LOCATION.: drains'andrain-drain packages)
Job site address:3/06 fl(wC G Pka- cJ 2 bathrooms/1 kitchen $411.00 $
City: S State:0 R ZIP:f 1q 77 3 bathrooms/1 additional kitchen $483.00 $
Q Each additional bathroom(over 3) $104.50 $
Reference: . Taxlot.: Each additional kitchen(over 1)- $104.50 $
;t ;`-_DESCRIPTION:-OF WORK 4'.1'-.E3; " Residential fire sprinklers(includes plan review)
N{4t/ 44ek//,, 7!e G 0 to 2,000 square feet $80.00 $
2,001 to 3,600 square feet $128.00 $
, "=PROPERTY`=OWNER <.7 Y" 3,601 to 7,200 square feet $192.00 $
Name: 5 4.
7,201 square feet and greater $255.00 $
Manufactured dwelling or pre-fab(circle one)
Address,77,C0 ®j(rC{ "leg" V Connections to building sewer and $80.00 $
/ water supply
City: far,1'h71(y id State: (fie ZIP:y)y7 a Commercial,industrial,and dwellings other than one-or
Phone: - - Fax: - - two-family
E-mail: . Minimum fee / $80.00 $
This installation is being made on residential or farm property Each fixture $21.00 $
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 $
CONTRACTOR' INSTALLATION Storm water retention/detention facility $21.00 $
Business name&a.t(r F�ow ,f t rig/ e-j r$ Irrigation systems $21.00 $
Piping or private storm drainage
Address:PO 4ox 7/.y5 2 systems exceeding the first 100 feet $21.00 $
City:sp�'� 1 Stated/C ZIP: 175'75- Specialty fixtures $21.00 $
Phoneft/J,29 SS 2 S FaxI'Vf t77 277 a Special requested snpeci neenorof) $80.00 $
Special reuted inspections(no.of
/ ` , e hrs.x fee per hr.) $80.00 $
E-mailGQ
G/���D.ri ti/���/J i' r eon-,
CCB licensenoi2C 07s
BCD license n0.: Each additional inspection:(1) $80.00 $
'Medical as' 1 m Minimum fee $
Plumbing license no.: � g PAP g '� .- , ,�
Print name: �if//l/j6ti.l; a/k/ p s7 —y7-�-= Enter value of installation and equipment$
7 i I — Enter fee based on installation and equipment value $
Signa -: _ - J—-r ' «al. a, .APPLICANT-`USE etat ,a"._
(A) Enter subtotal of above fees
(Minimum Permit Fee$80.00)
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(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): . $93 tf_ -
440-2500-J(4/1/2013/COM)