HomeMy WebLinkAboutPermit Plumbing 2004-06-28Building/Combination Permit
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
PERMIT NO: COM2004-00789ISSUED: 0612812004APPLIED: 0612812004
EXPIRESz 1212812004
VALUE:
SITE ADDRESS: 3252 MONTEBELLO A\ E
ASSESSOR'S PARCEL NO.: 1702193101005
PROJECT DESCRIPTION: Backflow Preventi,,rr Do ice
Springfield TYPE OF WORK: Backllow Device
TYPE OF USE: Addition
Owner:
Address:
MILLER SHIRLEY ANNE
3252 MONTEBELLO AVE SPRIN(;I'IELD OR 97477
Contractor Type Contractor License Expiration Datealo{Phone
b86 -q*15
C() NTRACTOR INFORMATION
LN\Arw,*uT-rri 4.fi'ol-
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group :
Primary Construction Type
Secondary Construction Typc:
# of Bedrooms:
Frontyard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Street Improyements:
Storm Sewer Available:
Special Instruction:
Notes:
# of Stories:
Height of Structure
Ty;le of Heat:
Water Type:
Range Type:
Encrgl,Path:
Sprinklcd Building:
Ovcrlal'Dist:
# Street Trees Rqd:
Par cd I)rive Rqd:
'h ol'Lot Coverage:
Lot Size:
Sq Ft lst Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:nla
$ Pcr Sq Ft
or nrrrltiplier
Square Footage
or Bid Amount
Sidewalk Type:
Downspouts/Drains:
REQUIRED PARI(NG
Total:
Handicapped:
Compact:
I]I ILDINC INFORMATION
PUITI-IC IN{I'
Valu
Description Type of Construction
Total Value of Project
Value Date Calculated
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Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Linc
Building/Combination Permit
PERMIT NO: COM2004-00789ISSUED: 0612812004APPLIEDz 0612812004
EXPIRESz 1212812004
VALUE:
Fces l)ai
Fee Description
+ l0o/o Administrative Fee
+ 1oh State Surcharge
Backflow Device
Miscellaneous Plumbing
Total Amount Paid
Amount I':rirl Date Paid
6t28t04
6/28t04
6t28t04
6t28t04
$4.s0
$3.t5
$14.()0
$31.00
Receipt Number
3200400000000000131
3200400000000000131
3200400000000000131
3200400000000000131
$52.(t5
Plan I{eviews
To Request an inspection call the24 hour recording at 726-3769. All inspection requested before 7:00 a.m.
will be made the same working day, inspcttions requested after 7:00 a.m. will be made the following work
day.
Backflow Device: Prior to covering and pr.rvitlc a copy of the test report on site at the time of inspection.
Rlrruired [nsnections
By signature, I state and agrec, that I have carefullr exarnirrcd the completed application and do hereby certify that all
information hereon is true antl corrcct, and I furtl,rr ccrtilr that any and all work performed shall be done in accordance with
the Ordinances of the City ol'Springfield and thc Liru's of t he State of Oregon pertaining to the work described herein, and
that NO OCCUPANCY will bc rnade of any strucr ,rre \r ithout permission of the Community Services Divisionn Building Safety.
I further certify that only conlractors and emplolcs u'ho are in compliance with ORS 701.005 will be used on this project.
I further agree to ensure that all required inspccti,rns are rcquested at the proper time, that each address is readable from the
street, that the permit card is located at the front ol'thc property, and the approved set of plans will remain on the site at all
times during construction.
Owner or Contractors Signature Date
Pase 2 of2
EET
22SFIFIHSTREET. SPRINGFIELD,OR97477 o PH:(541)726-3753 rFA)C6541)726-3689
City Job N .,-0",C rrn2cot-Co? 6?
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Job Location
Assessors
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BACKFLOW PERMIT IS $52.65 (includes Permit Fee, State Surcharge & Administrative Fee)
C o n tr a ct a y f nfo rm ati o n
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Construction Contractors Registration #Goal Expires U"(
By signing this permit/application, I agree to call for an inspection once the backflow prevention
devise has been installed and is visible for inspecti on (726-37 69). .I also state that all information on
this permit/application is correct.
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follow ru a opte the regon ity
Notification Center. Those rules are set forth
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0090. You may obtain copies of the rulesfrr Office Use
number for the Ore n Uti lity N
Date of A
checked for Delinquencies ' .-
checked for Historical Status l---'
Shared Drive (I:/Bpilding FormslBaclflow Preventionl-03.doc
CITY OF SPRINGFTELD, OREGON
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