HomeMy WebLinkAboutPermit Backflow Test 2004-9-1
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. CITY OF ~rKll'1ljl'1Ji,LU
Building/Combination Permit
PERMIT NO: COM2004-01096
ISSUED: 09/01/2004
APPLIED: 09/01/2004
EXPIRES: 03/01/2005
VALUE:
Status
Issued
1{
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 1320 MENLO LP
ASSESSOR'S PARCEL NO.: 1703273303300
Springfield
TYPE OF WORK: Backflow Device
TYPE OF USE:
New
Residential
PROJECT DESCRIPTION: BackfIow
Owner: PRUSZ CHAD W & KELLY R
Address: 1320 MENLO LOOP SPRINGFIELD OR 97477
Contractor Type
Landscape
III,GON'fRACTORINFORMATION I ORK
" - RMIT SHALL t!'.t'It'tt ,r 'IlL W
Contractor TH, ~~NDER THISInEeiUeT IS 001iration Date
LANDMARK I~~tW1', Q ,e: ARAf1i.l}~:NEO FOR 02128/2005
\"m,'lll'L,,::_= -.
J.BUlbm~:RMATION I
Phone
541-686-9493
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
VN
# of Stories:
Height of Structure
Type of Heat:
Water Type:
Range Type:
Energy Path:
Sprinkled Building:
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
R-3
nla
Frontyard Setback:
Side 1 Setback:
Side 2 Setback:
Rearyard Setback:
Solar SetbackS:
I DEVELOPMENT INFORMATION I
, REQ~PARKlNG
Overlay Dist: ~\EI1l!l~~\)\\\\t'J
# Street Trees R\!.~ttf\ON~ t6d bY\Wa a ''t.l\llIfa.ilb
Paved Drive Rqd? OW yUles adOP ~ '~2.a1\'o
% of Lot cover~\"ca\lon centef'10 UUOU9h ...,;. C\l\B9 '0)1
~ot\u 2-00'\-00 lesdl ,,- hOfIO
,,, C)~R ~~u ..,:'J nntaln co!_.~? taleP. . f._
I PUBLIC IMPROVEMBl'I'is,.il" n "'e c;en\8f. \"'n Uti\\\'1 ~o'l'u.o-
,.,J ",,'" e orego ,.i344).
"U\'lloeft8~'t~~~
C8ownspoutslDrains:
Street Improvements:
Storm Sewer Available:
Speciailnstruction:
Notes:
I Valuation Descriotion I
Description
Type of Construction
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Value
Date Calculated
Total Value of Project
Page 1 on
.
. CITY OF ~rK1Nu.nl!..Lu
, Building/Combination Permit
PERMIT NO: COM2004-01096
ISSUED: 09/0112004
APPLIED: 09/0112004
EXPIRES: 03/0112005
VALUE:
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
I F~~~ Pllill I
Fee Description
+ 10% Administrative Fee
+ 7% State Surcharge
Backflow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
$4.50
$3,15
$14.00
$31.00
9/1104
9/1104
9/1/04
9/1104
Receipt Number
2200400000000001118
2200400000000001118
2200400000000001118
2200400000000001118
Total Amount Paid
$52.65
I Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769. All inspection 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.
U~ouirell In.n~dinn~ I
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, and
that NO OCCUPANCY will be made ofany 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
times during construction,
~-rIO/V -:D~
'~or Contractors Sig~atur~ ~
7/ft, Y
DZ /
Paee 2 of2
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
,.
Job/Journal Number
COM2004-01096
COM2004-0 I 096
COM2004-0 1096
COM2004-0 1 096
Payments:
Type of Payment
Check
9/1/2004
.
RECEIPT #:
.'!'R~' IHCII'I",'M!__ '.'
WiL.
I. !
_~-.. l
ttliiti.ty of Springfield Official Receipt
.velopment Services Department
Public Works Department
2200400000000001118
Date: 09/0112004
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Backflow Device
Minimum! Adjustment Plumbing
Paid By
LANDMARK IRRIGA nON
Received By
djb
Page I of 1
Item Total:
Check Number Authorization
Batch Number Number How Received
1711
In Person
Payment Total:
11:53:23AM
Amount Due
3.15
4.50
14.00
31.00
$52.65
Amount PaId
$52.65
$52.65
22~ FIITH STREIT. SPRINGFIELD, OR 97477 . PH:(~4 J)726-37~3 . FAX: .~4J)726-3689
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Construction Contractors Registration #
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.
., CITY OF SPRINGFIELD, O'REGON
City Job Numb., C1)VV\ 'Z-OOL{ - 0 t 0 <t b
132-0 J1 GILD
170~ Z73~
LP
Tax Lnt
03"'3,00
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S~.ce.U
3~rS-CO a,/2-lf3
Zir 9')'1''-;1
Phonp
Statp dr-
N.OJJGt: . n E WORK
BACKFLOW PERM'f1~~~~ 61ilWd~~~~el~f~~~ Surcharge & Administrative Fee)
AUTHOR\ZEEOOUONRO~SR :~~~6~NEO FOR '
. COMMENC
Contractor Information ANY 180 OAY PERIOO.
Contractor f CA\A J) ~lc- ('fn"1 ~~~-
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Zip OJ'}\.{O I
Expires 1- / C? <"
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By signing this permit/application, I agr~~k~~Jjl!vA~!qU'eh~~i>~now prevention
devise has been installed and is visible fbl.\~~8e~~~~~g'llg~~a~~1 all information on
this permit/application is correct. \0 ~f-c~~Ofl :\.oO'\O\t\~o~le5o\ vJ.e~'{'i:)fle
~Q O~\,,\9PJ. tt\ ~ ~'.~ ~0'Uf,\~
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For Office Use
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Checked for Historical Status~
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