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HomeMy WebLinkAboutPermit Plumbing 2000-10-5 i:! . SPR.~IELD 225 FIFTH STREET SPRINGFIELD. OR 97477 (541) 726-3753 FAX (541) 726-3689 BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 Jf -------------------------------------------------------------------------------- JOB LOCATION: <,LG 0 L I ~rlAL'O DI} , ASSESSORS MAP #: I, 0 s ;;t '/ I J.... ,C;..oI2I~rJqFrejJj me. '. v TAX LOT #: 00 S cO ' - OImER: 3, W\ 'Au (,~lC L e_'I ADDRESS: (J,D, /":30)( L./>?DJ? CITY:TAlc..L 1;Je ,/ J J.a.c,<"" C7 PHONE #: 775-g,3/7J67 STATE: IUd, ZIP: ~'t<<)[J-t..;J'h BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMIN. FEE) = $16.50 CONTRACTOR: (R nr)S /J1r.ArY'I13,;vc ADDRESS: /7 2C, !)~K np V PHONE #{Sz.;n(:,o7-'g?c1o CITY: E CA;:t pAoJ.p STATE: f9-P - ZIP: 97t./{!Jej CONSTRUCTIO~ CONTRACTORS REGISTRATION #: / / () / I 7 EXPIRES: 01/0 =3102- 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. 1/\ '------ /0/',)";00 DATE S~ALb~a (' r' c;;/ FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: JOB #: RECEIPT #: ISSUED BY: ~ --< -":::1 "" J:> J:> TOTAL AMOUNT COLLECTED: ~ rM55 0..# ("') c:::ICJ.. :Do ..~o ----------------------------------------------------------------------------~- ~~~ :x: I 1--fC")t400 rr1 :r:: t.n 0 :::O::DU 0 ..:ZGJf<..)GJ om- ou QfTlOO....c .........OOtJ"1 . City'Of Springfield Development Services Community Services Division Building Safety I Job# 00-01496-01 Location Of Proposed Site: 460 Assessors Map#: 17032712 Lot: Block: Lindale Dr Spr Addition: Owner: Jim Buckley P.O, Box 4808 Phone Number: 775-831-7557 City/StatelZip: Incline Village, NV New Value: $0 Address: Scope Of Work: Backflow Device Fee Paid On Receipt# Plumbing 10/05/2000 3395 10/05/2000 3395 10/05/2000 3395 10/05/2000 3395 Minimum Plumbing Permit Fee State Surcharge For Plumbing Permit Backflow Prevention Device Plumbing Administrative Fee Total Plumbing Grand Total Required Inspections Scheduled Inspection Inspector Date Date Plumbing Backflow Device End Of Report . Tax Lot #: 00300 Subdivision: Value/Quantity Result Comments Pending Page 1 of 1 ~ ~ Fee Amount 1 $5.00 $1.05 $10.00 $.45 $16.50 $16.50