HomeMy WebLinkAboutPermit Backflow Test 2000-10-6
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SPRINGPIELD
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Job# 00-01502-01
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Page 1 of 2
TRANS#:01-0003409
DATE:OCT 06 2000
AMT RECD:2 $ 16.50
CHANGE:
CASHIER:061
225 North Fifth Street
Springfield, OR 97477
RESIDENTIAL PERMIT
City Of Springfield
Community Services Division
Building Safety
Job Number: 00-01502-01
Office: 726-3759
Inspection Line: 726-3769
Location Of Proposed Site: 756 Mckenzie Crest Dr Spr
Assessors Map#: 17032343
Lot: Block: Addition:
Tax Lot #: 02120
Subdivision: River Glen
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Owner:
GeorgelYvonne Karotk
4258 Franklin Blvd
Address:
Scope Of Work: Backflow Device
backflow device
Contractor Type
Landscape
Phone Number: 541-726-7625
City/State/Zip: Eugene, OR 97403
New Value: $0
Contractor
Hunter Irrigation and Landscape
25226 Strawberry Lane, Veneta, OR
97487
# Of Buildings:
Occupancy Group: Dwelling
Heat Source:
Sq. Footage:
'''UIIl;E:
To request an inspection call the 24 hour recording at 726-3769. All inspectionsJe~uested before 7:00
a.m. will be made the same working day, inspections requested after 7:dQf~"'rIi't"wiillb'E{rfi'a"de.iiieIf0f15wihg~EWORK
working day. AUTHORIZED UNDERTHISPERMITlS NOT
R . d I t' r:()MMJ:~I(,J::rof"'lDI'" ^D^"",",,,~,,_~_
eqUlre nspec Ions -. .- _. .__ , ~, .
I Plumbing ~NY 180 DAY PERIOD.
-After device is installed but before backfilling trench.
Quad Area:
# Of Units:
Constr. Type:
Water Heater:
1
(VN) Wood Frame
Backflow Device
Construction Types:(VN) Wood Frame
Occupancy Groups: Dwelling
# Of Buildings:
# Of Bedrooms:
Handicap Access? 0
iArea (Sq. Feet)
I Main: Accessory:
Fee
Minimum Plumbing Permit Fee
Registration # Expiration Date
Phone
- Office Use
Land Use:
Zoning Code:
Bedrooms:
Range:
--
Store AlTENTION:OregC'n law requires you to
# Of Stories: fo!'?j:f~ldAt:{fil9t)!ed by the Oregon Utility
Current Units: !"o~tl~~~p:ds~atonit~~1se rules are set fon
Census Code:New SF -~r hag 2-001-001~thro~ghOAR952-001'
u ..11 u may obtain coplasof the rulas by
. I callmgthecenter.(Note:thetelaphone
Total. numberfortheOregon Utilitv Notifjr.~tjnn
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Paid On Receipt# Value/Quantity' Fee Amount
I Plumbing I
10/06/2000 3409 $5.00
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Job# 00-01502-01 I'
Paid On Receipt#
Plumbing
10/06/2000 3409
10/06/2000 3409
10/06/2000 3409
10/06/2000 3409
Fee
State Surcharge For Plumbing Permit
Water Service Line w/Bath Permit
Backflow Prevention Device
Plumbing Administrative Fee
Total Plumbing
Grand Total
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Page 2 of2
Value/Quantity Fee Amount
I
1
$1.05
$.00
$10.00
$.45
$16.50
$16.50
By signing this permiVapplication, I agree to call for an inspection once the backflow prevention
device has been installed and is visible for inspection (726.3769). I also state that all information on
this permit application is true and correcl.
Signature
Date
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SPRINGFIELD
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 15 h "hfbh./Jwtf! r'~l}~
," ASSESSORS MAP II: SE ;Y S.R~, ~3 7:/?,f). TAX LOT 11:)(.3 /-1/") I-V'. h1,
"/~ 1/' ~ 170 3'Z..'3,4~ CZI2..0 .
OIINER: ~~R J/r-J~
ADDRESS: V!-J-i ;;;JC_o/R.//f(Y-' r-JA/.Ar.:h- PHONE 1I:..\...t;"'W-,/c"3.,<; -/h/j>
, CITY: ~jl STATE: r7 J;J ZIP: 979>7"
BACKFLOII PERMIT IS $15.00 +1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR: JI u--",~",('Z/('A";e:,#77...." H---<t? k",L?f""-"'p""" X-~ t::C..
ADDRESS: 2.r::z. ")..~ ~/ "'1'4"-,UA:/ 2....r PHONE II: ~r,r-;- J.2/.S-
,
CITY: J/-<-,^,....::T'7.}- STATE: ~A'.
CONSTRUCTION CONTRACTORS REGISTRATION I: 1'/37::2..
ZIP:
EXPIRES:, ,-/-.3t9-(!)/
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR I~SPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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, SIGNATURE[:!
7~c2 cY-do
DATE
FOR OFFICE USE
----------------------------------~---------------------------------------------
DATE OF APPLICATION: I CC) G e 0
RECEIPT II: >'-'10"7 ISSUED BY:
JOB II: eO - 0/50l.-01
TOTAL AMOUNT COLLECTED:
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