HomeMy WebLinkAboutPermit Plumbing 2000-10-5
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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
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JOB LOCATION: <,LG 0 L I ~rlAL'O DI}
, ASSESSORS MAP #: I, 0 s ;;t '/ I J....
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TAX LOT #: 00 S cO '
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OImER: 3, W\ 'Au (,~lC L e_'I
ADDRESS: (J,D, /":30)( L./>?DJ?
CITY:TAlc..L 1;Je ,/ J J.a.c,<""
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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.
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DATE
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FOR OFFICE USE
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DATE OF APPLICATION:
JOB #:
RECEIPT #: ISSUED BY: ~ --<
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TOTAL AMOUNT COLLECTED: ~ rM55
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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
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~
Fee Amount
1
$5.00
$1.05
$10.00
$.45
$16.50
$16.50