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HomeMy WebLinkAboutPermit Backflow Test 2000-10-6 . i ., SPRINGPIELD ~., . Job# 00-01502-01 . 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 ~ 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 '_ ._--_,__, n_." -.rr -., - ') -~.......,.- . .....vd-....h......;;-..:;~ Paid On Receipt# Value/Quantity' Fee Amount I Plumbing I 10/06/2000 3409 $5.00 , , . 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 . 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 " . . . SPRINGFIELD " BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- , 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. ~~ , 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: ~ -n:" -l :l:>~ ::O-lZ I"T1l"T1en " """ M_g~~ ---------------------------------------------------------~------------------~- .. Me> " " en r-.J-l.... ~Qt4~6 :::0::0...... g .. :zo--Nl"J om. o~ O"rr'lO'Ioo ........00....0 -:hI? .lh~V