HomeMy WebLinkAboutPermit Plumbing 2003-05-14City of Springfield
Plumbing Permit
Status: Issued
225Fifth Street
Springfield, Oregon 97477
54t-726-3759 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
PERMIT NO.:
ISSUED:
APPLIED:
EXPIRES:
PLM2003-00026
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TYPE OF WORK:
TYPE OF USE:
New
Residential
ASSESSOR'S PARCEL NO.: 1702314401666
PROJECT DESCRIPTION: Backflow device
OWNER/APPLICANT:
MEYERS TIMOTHY L & VALERIE A
56I S 4OTH ST
SPRINGFIELD OR97478
PLUMBING CONTRACTOR:
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IHIS PERMIT
AUTHONIZECI
COMMINCIED
Phone:
EXPIRE IF THE WORK
THIS PERffifi% ruOT
SHALL
UNDER EXPIRES
Descrintion
+ l0o/o Administrative Fee
+ 7Yo State Surcharse
Backflow Device
Minimum/Adiustment Plumbine
4.s0
3.l5
14.00
31.00
Date Paid
0511412003
0511412003
0s11412003
0s11412003
Receipt Number
1200200000000001 193
1200200000000001 193
1200200000000001 193
1200200000000001 193
To Request an inspection call the 24hour recording at726-3769. All inspections requested before 7:00 a.m. will be made the same
working day, inspections requested after 7:00 a.m. will be made the following working day.
Required Inspections:
1 Backflow Device: Prior to covering and provide a copy of the test report on site at the time of inspection.
By Signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springfield and the laws of the State of Oregon pertaining to the work described herein. I further
certify that only contractors and employees who are in compliance with ORS 701.055 will 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 plans, if applicable, wiII remain on the site at all times during construction.
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Owner or Date
225 Fifth Street
Springfield, Oregon 97 477
541-726-3759 Phone
City of Springfield
Development Services Department
Public Works Department
Official Receipt
Receipt #z 120020000000000 I I 93 Date: 0511412003
PLM2003-00026
PLM2003-00026
PLM2003-00026
PLM2003-00026
Back{low Device
Minimum/Adj ustment Plumbing
+ lUYo Administrative Fee
+ 7Yo State Surcharge
Payments:
14.00
31.00
4.50
3. l5
Item Total:$52.6s
Check TIMOTHY MEYERS djb In Person
Payment Total:
52.65
$s2.65
s/r4t2003 2:51:57PM Page 1 of I cReceipt.rpt
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225 FIY|H STREET . SPRINGIIELD, OR 97477 o PH:(541)726-3753 o FAX: (541)726-3689
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BACKFLOW PERNIIT lS $52.65 (includes Permit Fee, State Surcharge & Administrative Fee)
Con trs ctor I nform ati on
Arrne-/Contractor
City
Construction Contractors Registration #
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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Expires
For Office Use
d<Date of Application
Checked for Historical StatusChecked for
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Shared Drive (T:)lBuilding Fonns/Backflow Preventionl-03.doc
CITY OF SPRINGFIELD. OREGON
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