HomeMy WebLinkAboutPermit Plumbing 2000-05-17SPRINGFIELD
Job# 00-00746-01
RESIDENTIAL PERMIT
City Of Springfield
Community Services Division
Building Safety
Page 1 of 2
TRANSS:01-0001-?EI
DATE:itAy lT 1000
AHT ftEID;? $ 1&.5ir
*=*!ENTHE;
225 North Fifth Street
Springfield, OR97477
Location Of Proposed Site: 353 00018TH St Spr
AssessorsMap#: 17023624
Lot: Block: Addition:
Job Number: 00-00746-01
Office:726-3759
lnspection Line: 726-3769
Tax Lot#: 00900
Subdivision:
CITY OF SPRING FIELD, OREoON
Owner: GUT DENT
Address: 353 IBTH ST
Scope Of Work: Backflow Device
Phone Number:
City/State/Zip:
New
541-736-8626
SPRINGFIELD, OR 97477
Value: $0
Office Use
\rQuad Area:
# Of Units:
Gonstr. Type:
Water Heater:
To request an inspection call the 24hour
a.m. will be made the same working day,
working day.
Backflow Device
La Of Buildings:
ltrts FOR Occupancy Group:
Heat Source:
Sq. Footage:
All inspections requested before 7:00
after 7:00 a.m. will be made the following
@
oR\3
req uested
Required !nspections
Construction Types:
Occupancy Groups:
# Of Buildings:
# Of Bedrooms:
Handicap Access?
Area (Sq.
Main:
Plu
-After device is installed but before
Accessory:Total:
backfilling trench.
,il
Height (feet):
Proposed Units:
not apply
Fee Paid On Receipt# Value/Quantity Fee Amount
Minimum Plumbing Permit Fee
State Surcharge For Plumbing Permit
Backflow Prevention Device
Plumbing
05t17t2000
0511712000
05t17t2000
$5.00
$1.05
$10.00
1782
1782
1782 1
\S No;
"rtq
#of
Current
\oe
I
Census Code:
Job#Page 2 of 2
Fee Paid On Receipt#Value/Quantity Fee Amount
Plumbing Administrative Fee
Tota! Plumbing
05117t2000 1782 $.45
$16.50
Grand Total $16.50
5- rl-oo
By signing
device has
this
this permiUapplication, I agree to callfor an inspection once the backflow prevention
been installed and is visible for inspection (726-3769). I also state that all information on
application is true and correct.
Signature Date
SPRIi.GFIELD
BACKFLOIJ PREVEMION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFTCE: 726-3759
JOB LOCATION: Z5 3 /S. S;.
ASSESSORS MAP *:
OI,INER: G r^f
l? 03 36 ?-r"[TAX LOT #:9oo
tJ Drl t
CITY OF OREGO'V
ADDRESS. 35) (\t, si--PHoNE *: 7l t t t"i t
CfTY: 3(<.*- tz,iL?STATE: G4 ZIP: ? r i-f?? -y ?/ 6
BACKFLOI.I PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR:
ADDRESS:PHONE *:
CITY:STATE:ZIPt
CONSTRUCTION CONTRACTORS REGISTRATION #:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPBCTION ONCE THE
BACKFLOU PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
€--:S-i?-ss
DATE
FOR OFFICE USE
DATE OF APPLTCATION:
RECEIPT *:
TOTAL AHOI'NT COLLECTED:
ISSUED BY:
JOB *:c-