HomeMy WebLinkAboutPermit Backflow Test 2013-9-18 tt
SPRINGFIELD 225 Fifth St
' ' CITY OF SPRINGFIELD Springfield,OR 97477
,: Cell's:- Phone: 541-726-3753
--, OREGON Building / Residential Permit Inspection Phone: 541-726-3769
Fax: 541-726-3676
PERMIT NO: 811-SPR2013-02100
wwwspringfield-or.gov permitcenter @springfield-or.gov
PROJECT STATUS: Issued ISSUED: 09/18/2013 EXPIRES: 03/17/2014
STATUS DATE: 09/18/2013 APPLIED: 09/18/2013
SITE ADDRESS: 2350 10TH PL,Springfield,OR 97477 SCOPE: Backflow Device
ASSESOR'S PARCEL NO: 1703261203400 TYPE OF STRUCTURE: Residential
PROJECT DESCRIPTION: Backflow device
OWNER: YOUNG RAYMOND ATE Phone Number:
ADDRESS: 2350 N 10TH ST
SPRINGFIELD OR 97477 •
CONTRACTOR INFORMATION
Contractor Type Contractor Name Lic Type Lic No Lic Exp Phone
Plumbing Contractor OWNER CCB 000000 08/01/2025
INSPECTIONS REQUIRED 1
Inspections
3620 Backflow Device Backflow Device: Prior to covering and provide a copy of the test report on site at the
time of inspection.
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
construct
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Springfield B uilding Permit 9/18/2013 11:29:47AM Page 1 of 1
SPRINGFIELD CITY OF SPRINGFIELD
kr gyp,,. 225 Fifth St
•
�CO OREGON TRANSACTION RECEIPT Springfield,OR 97477
541-726-3753
811-SPR2013-02100
www.springfield-or.gov 2350 10TH PL permitcenter @springfield-or.gov.
RECEIPT NO: 2013002059 RECORD NO:811-SPR2013-02100 DATE:09/18/2013
(DESCRIPTION `_ ACCOUNT-CODE/TRANS-CODE_ —:AMOUNT DUEJ
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
PAYMENTTYPEw_: .PAYOR_.;_cASHIER:DBOWLSBY _ _ _ - _ COMMENTS. __ __
COMMENTS -,,._ AMOUNT PAID_ - - _ ;
Credit Card joseph spivick 93.60
06562c
TOTAL PAID: 93.60
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•
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Plumbing Permit Application DEPARTMENT USE ONLY
, . s SPRINGfIELO
CITY O SPRINGE;I'EL D�OREGO -w- Permit no.: S/7 - 0a (O o
225 Fifth Street • Springfield. P I
OR 97477 ♦ PI3(541 G 37 3 • A\(541)726 1689
f . OREGON Date:
y,43
This permit is issued under OAR 918-780-0060. Permits are issued only to the person or contractor doing the wok. Permits
expire if work is not started Witllin 180 days of issuance or if work is suspended for 180 days.
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? ❑ Yes ❑No Description Qty. Cost Total
ca. cost
Sanitation approval verified? ❑ Yes ❑No New residential
CATEGORY OF CONSTRUCTION I bathroondl kitchen(includes:first
10!)feet of rnler'/seu'er lines, hose
❑ Residential ❑Government ❑ Commercial $262.00 $
bibs, ice ranker. rurderAoor low-pole!
JOB SITE INFORMATION AND LOCATION trains and rnio-rlra/n packages)
Job site addres O
s: Sc) 1, ) Q}1 c 2 bathrooms/1 kitchen $411.00 $
3 bathrooms/I kitchen $483.00. 5
City: Slat _ Zl P. 7((9 7 Each additional bathroom(over 3) $104.50 S
Reference: ,7b 3 Z.Sit Taxlot.b act p b Each additional kitchen(over I) $104.50 S
DESCRIPTION OF WORK Residential tire sprinklers(includes plan review) ___
tack_ ,LOW 3 fit/(Ce 0to?000 square feet __ $80.00 $
2.1101 to 3.600 square feet 5128.00 $
PROPERTY OWNER 1601 In 7,200 square feet $192.00 $
Name: 7,201 square feel and greater 5255.00 $
U�� yU VN I RIanufaetrtred dwelling or pre-fab(circle one)
Address: b N. j 0 t h Connections to building sewer and $80.00 $
CCity: �J q Q State: U p� ZIP: l7 17 `c,urr supply
Commercial,industrial,and dwellings other than one-or
Phone: 6Llf , 1'-(a-(b3)- Fax: A/01\c, two-family
E-mail:. l
Minimum fee $80.00 $
N0Nc
.............-. 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 NIiscell:meous fees
exempt from licensing requirements under OAR 918-695-0020. 100' storm,sewer. water line 583.50 $
Signature: Each fixture,appurtenance.and piping $21.00 $
CONTRACTOR INSTALLATION Storm water retention/detention facility $21.00 $
Business name: FApmwoftk) hl;nnprsty -� /�/}ULlkp� $21.00 $ —
()AD., system ecettc storm dt a loge
p �mh
Address: p�j 1 1 )-}R�-_�, p - exivedine the test I(lU feet $21.00 $
City: 4j4—ri_Af& I Stale: OA_ ZIP l)9 3 Specialty fixtures $21.00 $
vi ��5-1 Reinspecuun(no.of hrs.x fee per hr.) $80.00 S
Phone: Kf Pax: �/Q `-
i Special hcyuesled inspections(no.of 580.00 $
E-mail: r ' hrs..x lee per hr.)
ovS l�orke� nice .� n1�
tro
licenk no.: P60 B D license n0.: Each additional inspection:111 $80.00
/Ma Plumbing license no.: p Ind2 41 41 69,_q6 Medical gas piping Minimum ice $
�• filler value of installation and equipment$
Q��h b
Print nanhc:_ J�J NA(
f 11 Finer tee based on installation and equipment value. $
Signature:
APPLICANT USE
(A) Enter subtotal of abnre fees
(1llininuun Permit Peal) $
(13)Investigative fee(equafto 1Al) $
(C)Enter 12%surcharge(.12 e[Al-RI) .$
(D)Technology Fee(5%of[A]) $
TOTAL fees and surcharges(A through D): $ '36-0
-140-2500-.114/1/201 WONI)