HomeMy WebLinkAboutPermit Backflow Test 2009-2-6
CITY OF SPRINGFIELD -
Building/Combination Permit
PERMIT NO: COM2009-00182
ISSUED: 02/06/2009
APPLIED: 02/06/2009
EXPIRES: 08/0612009
VALUE:
G
Status
Issued
, 225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 1026 J ST
ASSESSOR'S PARCEL NO.: 1703264413700'
Springfield TYPE OF WORK: Backnow Device
TYPE OF USE: New
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage: .' .
NO,.ICE.:"" cuM \ f)(?IRE If I~J'~~I~~
1~~~lJ~r~N~~'rOR
COMMENCED U~ \~D.J' .. Sidewalk Type:
ANY 180 DAY PERI. DownspoutslDrains:
PROJECT DESCRIPTION: Backnow device
Owner:
Address:
HELEN B BRUZER REVOCABLE LIVING TRU
1026 J ST
,SPRINGFIELD OR 97477
Contractor Type
Landscape
I.<:ONTRACTOR INFOR~ATION .
, Contractor. laW requireS yauti.O~ense
OASIS IRRIGAT10'Nq,X;G:~hV tM orego~~ ~~lt\li
. '; .. ,~ -, - ", ,,~"".....' - -/
- ,~;,;~n-,I':BUILDI~G'INF0RlVI>\']II~Ii"'1i
I . '-?_('O",\~uv lV .... .~ 01 tne \.Ulv..., -J
j- _~',\{~\~ay o#tof%(o~~~:~M telephone
VL:'~-3no the cenHeig~l,~t;St"uctu?~ilicatlOn
C~\I\l'... ~r~gu I V'''"1 )
n1\mber lor the!YP:'83!i't'CJ!J:2344 .
VB center Water Type:
Range type:
Energy Paih:
Sprinkled Building:
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
I DEVELOPMENT INFORMATION I
Fronlyard Setback:
Side 1 Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Street Improvements:
Storm Sewer Available:
Special Instruction: , '
~
,
Notes:
I Val~ation Descriotion I
Description
Type of Construction
$ Per Sq Ft
or multiplier
Square'Footage
or Bid Amount
Paee 1 01'2
Residential
Expiration Date
01/31/2010
Phone
541-343-7482
n/a
Lot Size:
SqFt 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
REQUIRED PARKING
Total:
Handicapped:
Compact:
~
Value
Date Calculated
Status
Issued
CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2009-00I82
ISSUED: 02/0612009
APPLIED: 02/0612009
EXPIRES: 08/06/2009
VALUE:
~~
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Total Value of Project
Fees Paid I
Fee Description
+ 12% State Surcharge
+ 5% Technology Fee
Backllow Device
Minimum/Adjustment Plumbing
AmountPaid
Date Paid
Receipt Number
$6.96
$2.90
$19.00
$39.00
2/6/09
2/6/09
2/6/09
2/6/09
2200900000000000148
2200900000000000148
2200900000000000148
2200900000000000148
Total Amount Paid
$67.86
I Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769. 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
work day.
I. .R,eo,!i.~~~ Tns'Jection.~ I
Backllow Device: Prior to covering and provide a copy of the test report on site at the time of inspection.
By signature, 1 state and agree, that I have carefully examined the completed application and do hereby certify tbat 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, and
that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety.
I further certify that only contractors and employees who are in compliance with ORS 701.005 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, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all
timesdurinr;~\).,~ L-~ -04
Owner or dlDtractors Signature Date
Page 2 of2
225 FlFI1I STREET. SPRINGFIELD, OR 97477 . PH:(541)7Z6-3753 . FAX: (541)726-3689
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Job Location /OZ- G '-S- os,
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Contractor
Address
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State 0 (L Zip ~ '( Lf 0 IS
C:;S-l'lG Expireo \~ ~ (_C(J \ ~
City
Construction Contractors Registration #
By signing this permit/application, I agree to call for an inspection once.~; ~ow prevention device
has been installed and is visible for inspection (726-3769). I also st{~~ ~rmalion on this ,
permit/applicatio is correct. C~:. t>,\.\. 'Cf-.?\<r; ?'t.?-\J\\" ?-
Sig""'~ awt52 ~~~~o~~"""'"~~,. 'V<) -O{
CGWI\~\\. . Ull.'l \,\:."r_ ,
p.~'l "\ 'O\)
For Office Use
Date of Application
~/~o~
Checked for Delinquenci~.
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Checked for Historical Stah,.
, /
Shared Drive {T:)lBuilding Forms/Backtlow Prevention 7...{l8.doc
225 Fifth Street
~'lringfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2009-00 182
COM2009-00 182
COM2009-00 182
COM2009-00] 82
Payments:
Type of Payment
Check
.cReceintl
RECEIPT #:
City of Springfield Official Receipt
Development Services Department
Public Works Department
2200900000000000148
Date: 02/06/2009
[)escription
Backflow Device
Minimum/Adjustment Plumbing
+ 5% Technology Fee
+ 12% State Surcharge
Paid By
OASIS IRRIGATION LLC
Item Total:
l.:heck Number Authorization
Received By Batch Number Number How Received
djb
6304
In Person
Payment Total:
!
Page I of I
9:23:06AM
Amount Due
19,00
39,00
2.90
6,96
$67.86
Amount Paid
$67,86
$67.86
2/6/2009