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HomeMy WebLinkAboutPermit Plumbing 1995-3-28 OM/>? . ., ,;..:~. i" SPRINGFIELD 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION -------------------------------------------------------------------------------- 9 f'D IS' Wn.:J . ASSESSORS MAP II: J7Y1::l""22-~ OlmER: ~~O,^.> ~~----r,;- ADDRESS: 9 f'D I\~. LN.../ 41U JOB LOCATION: TAX LOT II: ~ 9/2 ;2.h..AA..<.. '"-'" CITY: STATE: ~ PHONE II: ? 2...<';; - c: SS? ZIP: '77 Y7? " BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: C!.o../lJ ReftA.-;;- _Jet-v /c..... ./? J" Dh. /'u. r 1C1 L/ PHONE II: .' ADDRESS: 37</7(, (l r 1ft. (""Ov.P ~ cr CONSTRUCTION CONTRACTORS REGISTRATION II: STATE: ()k t) !'I.( ss'f I 7'-/(;,_ 6J7U ZIP: ~7 YO.S- EXPIRES: /0 - / - 5: 5- CITY: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769), I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. , _ /JL~/~ SIGNATURE .- J - .? S-. 9,- DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: ?,.:zg.~ RECEIPT II: /6774' ISSUED BY: TOTAL AMOUNT COLLECTED: /~ . 2e:> JOB II: 9Y/3'Y~ ~--. 'ff'" -'- -------------------------------------------------------------------------------- . ......-....-... -- JOB NO, qql?Y-? ~ITY O~PRINGFIELD~YSTEMS DE~EL~NT CHARGE WORKSHEET (COMMERCIAL & RESIDENTIAL) NAME OR COMPANY: P~VID AND~E;\4.IS LOCATION' cq'Oo KfLIJ5>E; WAY 1"102,202'2.0 - 9\'Z.. DEVELOPMENT TYPE: c..C: 'Rf:.o::.T'A.UIZ....At-J"f.!; ~€:'NE.I1..:-{ BUILDING SIZE: tOT SI7F 1, SIQEM nRATN~ SQ. Ft. IMPERVIOUS SQ, FT. \ "I6~'2.. X SO.209 PER SQ. FT. $ Yl0~o<l 2. SANTTARY SFWFR-CTTY NO. OF PFU'S' ., (See Reverse) X $43.26 PER PFU . .' $ ?Oi , *(, @ NO OF UNITS X TRIP R~TE X COST PER TRIP ~~~ ~~,~iPIJ1l.O,o.l."( tf,i'-l'O X .,bb XS436,19 ~faY1~ $11?8"'-I-o~~~\~fl1 "o€ ,~O 'Z., \ 10 o...,? (It:::'r11J ~ ,;11 qo ~ rv ~AN\J~"C.:1'ul4>1.('- ';;L ~ X :"Z--hl X S43~:19 tJ;DfTJ ,qq; $ 109 - \~f X X S436.19 $ 3. TRANSPORTATTON SUBTOTAL (ADD ITEMS 1.2, & 3) $ 4. S8NlIARY SFWFR-MWMG NO, OF PFU'S 11 x S17.19 PER PFU .;. $10 MWMC ADMIN.FEE $ 1~2.~q (Use' PFU Total From Item 2 Above) ; . .! HwMC: CR~~IT" .IF' APPpCABLE (~EE RE~ERSE) .. Ealane.e.- $": 40 ,8.1 :-O....~f>~~ '. ~ '. ," . IQIA'.-MWMC snr.- (fJ)=1 $ P,'I~c..eC:-'(f?\Q:5u,,\ SUBTOTAL (ADD ITEMS' 1.2.3 & 4) $1.'-I?"i~. \Ot'-.\1:J . . ~ 5:' ~OMTNTSTATTVF-FFf~.. ~ . . .. BASE CHARGE (SUBTOTAL ABOVE) X ,05 $ 1'Z1.B~~ ~'L) "BL..k. ~ ~ry Hornig. P,E, $bc Coordinator Date: 10/10 /a,y. , / B2.SDC . . , "". TOTAl SOC $ cl3>.'1? ?,!. . 0...'0 ~ V\~\\v~~'1~__ tu:m