HomeMy WebLinkAboutPermit Plumbing 2003-01-22City of Springfield
Plumbing Permit
Status: Issued
225 Fifth Street
Springfield, Oregon 97 477
541-726-3759 Phone
541-726-3676Fax
541-726-3769 Inspection Line
PERMIT NO.:
ISSUED:
APPLIED:
EXPIRES:
PLM2003-00006
u22t2003
u22t2003
7t22t2003
SITE ADDRESS: 1377 MOHAWK BLVD
ASSESSOR'S PARCELNO.: 1703253403901
PROJECT DESCRIPTION: Install backflow device 10
Springfield
TYPE OF WORK:
TYPE OF USE:
New
Commercial
503CORPUMPQUA HOLDING
2OO SW MARKET ST
PORTLAND OR 9720 o\
900
c
STE
I
OWNERYAPPLICANT:
Descrintion
+ l0% Administrative Fee
+ 7o/o State Surcharge
Backflow Device
Minimum/Adiustment Plumbine
IRzuGATION CORP
RD PMB 305
oR 97401
r-686-9493
6049 E)0IRES: 02/2812003
Receint Number
l 200200000000000587
1200200000000000s87
I 200200000000000s87
l 200200000000000587
\$
C 0U2212003
0U2212003
0v22/2003
0t/2212003
3.15
14.00
31.00
To Request an inryection call the 24 hour recording at726-3'169. All inspections I be made the same working day,
inpections requested after 7:00 a.rn will be made the following
Required Inspections:$ss
1 Backflow Device: Prior to covering and on site at the time of inspection.
By Signature, I state and agree, that I have carefully completed application and do hereby certify that all
information hereon is true and correct, and I further that any and all work performed shall be done in accordance
with the Ordinances of the City of Springfietd and the laws of the State of Oregon pertaining to the work described herein. I
further certiff that only contractors and employees who are in compliance with ORS 701.055 witl be used on this project I
further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the
street, and that the approved set of if applicable, will remain on the site at all times during construction.
\
Owner or Contractors Signafure
o3
-r
t/22/2003
l:43:00PM
City of Springfield '
Development Services Department
Public Works I)epartment
Official Receipt
225Fifth Street
Springfield, Oregon 97 477
541-726-3759 Phone
Receipt #: 1200200000000000587
Date: 0112212003
Line ltems:
JoUJournal Number Description Amount Paid
PLM2003-00006
PLM2003-00006
PLM2003-00006
PLM2003-00006
Backflow Device
Minimum/Adj ustment P lumbing
+ l0% Administrative Fee
+ 7Yo State Surcharge
Payments:
14.00
31.00
4.50
3. l5
Line ltem Total:$52.6s
Tlpe of Payment Paid By Received By Check Number Confirm No How Received Amount Paid
Check LANDMARK IRzuGATION djb In Person 52.65
Total:$s2.6s
Page I of 1 cReceipt.rpt
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225 IIFII{ STREET . SPRINGFIELD, OR 97477 r PH:(541)726-3753 o FAX: (541)726-3689
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BACKFLOW PERMIT IS $52.65 (includes Permit
C o ntractor Information
Contractor llvaO"rf
l5l LoL"
City 8.,
Construction Contractors Registration #ov1
By signing this permit/application, I agree to call for
devise has been installed and is visible for inspection
this permiVapplication is correct.
D
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Use
Date ofApplication ZZ o7
Checked for Historical Status
the backflow prevention
state that all information on
27-o
Checked for Delinquenci es
Sbared Drive (T:/Building Forms/BacKlow Preventionl{3.doc
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