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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 D \m r@ 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? Tax Lot O t croSlq Job Location Assessors F4HA,\J r1{ *pJ. C.,s: () t,tFd. tq{"a.i..J.{tnFL{ {, Owner Mi \ \e--. 5h ,r Lr.,r, O^^r-- Address I\ 3LSz l o,-\*-b<-t Io \ City €oa,--G"Y]Ot-?1.+r -lctatezip I 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 Contractor tA,\A lc trri ^,tt.:--t:-?zt c.*- S tete X 'llvo Izip 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. -i-*, r. t-=(i (i'1rltht $-{ (,).: A l.J-{, (). c.)r 1;{ q.),nlq{ -lFr(A\J .. r={,, -hal:?1F{ G,)," €),$i,F\hfr{ bAV, F-(,L{-{VFl ()t d]na\i{-{ City ENTI W uto follow ru a opte the regon ity Notification Center. Those rules are set forth ti 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 phon" ?ZG*loSY t Phone