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HomeMy WebLinkAboutPermit Backflow Test 2000-12-13 --4, . . " I Job# 00-01782-01 I Page 1 of2 TRANS#:01-0004021 DATE:DEC 13 2000 AMT RECD:2 $ 16,50 CHANGE: CASHIER: 061 OO.~O, Job Number:-OO o+";,ef 61 CITY OF SPRINGFIELD, OREGON 225 North Fifth Street Springfield, OR 97477 RESIDENTIAL PERMIT City Of Springfield Community Services Division Building Safety Office: 726-3759 Inspection Line: 726-3769 location Of Proposed Site: 788 McKenzie Crest Dr Spr Assessors Map#: 17032343 lot: Block: Addition:3rd Tax lot #: 02102 Subdivision: River Glen ~ Owner: Future B Inc. Po Box 7425 Address: Scope Of Work: Backflow Device backflow device Phone Number: 541-744-2660 City/State/Zip: Eugene, OR 97401-0017 New Value: $0 Contractor Type landscape Contractor Delta Landscape Irrigation Inc Po Box 40217, Eugene, OR 97404 Phone 541-688-9144 Quad Area: # Of Units: Constr. Type: (VN) Wood Frame Water Heater: Registration # 119285 Expiration Date 1/6/2002 Office Use land Use: Zoning Code: Bedrooms: Range: # Of Buildings: Occupancy Group: Dwelling Heat Source: Sq, Footage: To request an inspection call the 24 hour recording at 726-3769. All insRections requested before 7:00 a.m. will be made the same working day, inspections requested after 7-:oQT.I;1H.I~ill\lie'maa€ine'following you to working day. follow rules adopted by the Oregon Utility Notification Center. Thuse cules are set forth Required Inspectiol]~ LJ1\t1 ::Iot:-uu I-UU lumrullgnu~t1 ~::>~-UU1- I Plumbing OU~O. You may obtaill capias of the rules by Backflow Device -After device is installed but before backfillin(jftiWricti~e c;entm. ,1'Jotd: tha telephone nwnbdrforthe Oragon Utility Notification C~i"tl..r if i -?"'. J-:1~:2.. ~844). Construction Types:(VN) Wood Frame Occupancy Groups: Dwelling # Of Buildings: # Of Bedrooms: Handicap Access? 0 ,Area (Sq. Feet) I Main: Accessory: Fee Minimum Plumbing Permit Fee Accessory Structure # Of Stories: Height (feet): Current Units: Proposed Units: Census Code: New SF - detacn,ebTICE: Total: I THISPERMITSHALLEXPIREIFTHEWORK ft""" .".....___..."_ ___ Paid On Receipt#.1MENLVll!u~!q~~!1!jtymnl\lI:If!l,e;~_mo~nt Plumbing ANY 180bAYPERIOD. 12/13/2000 4021 $5.00 .-:.. . . Job# 00-01782.01 I Page 2 of2 Fee Paid On Receipt# Value/Quantity Plumbing 1 12/13/2000 4021 12/13/2000 4021 1 12/13/2000 4021 Fee Amount State Surcharge - Plumbing Backflow Prevention Device Administrative Fee - Plumbing Total Plumbing Grand Total $1.05 $10.00 $.45 $16.50 $16,50 By signing this permiVapplication, I agree to call for an inspection once the backflow prevention aV' ha.s been installed and is visible for inspection (726-3769). I also state that all information on t . pe mit application is true and correct. ty'4 j7...-7 / Z rf. l' -&C? Signature / I / Date . - " . . DEVELOPMENT SERVICES DEPARTMENT 225 FIFTH STREET SPRINGFIELD, OR 97477 (541) 726-3753 FAX (541) 726-3689 BACKFLOY 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: 7-t7f 1I'Y\rY../l'/?,'C- /Y'r-jT (7L ASSESSORS HAP #: OYNER: Q,L~ I .,..~I", uJ ADDRESS: tlfJ< n' ,,~,-f'/ t7l7fJ-. .. - CITY: EVf~ STATE: v TAX LOT #: PHONE #:.izjfb -:4f7 ~ I9L ZIP: 4 ?Z/t::J5' . BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMIN. FEE) = $16.50 CONTRACTOR: 0'-1_"'''4 /..ftN(}~ftI'E ADDRESS: "C't./I!_lL<J P'O Pvrl< tlt'J:?-/? CITY: r::::. v5~ Y'-C STATE: Ct;1!... CONSTRUCTION CONTRACTORS REGISTRATION #: IIL.t-It:J PHONE #: !_?~ "''YJt/Cj ZIP: ~ 72.JtY/' EXPIRES: //- ~ZotJl ( BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTIO~ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION -. (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. . n~ SIGNAl:9RE / , -- /77 /2--J5-cPO DATE , FOR OFFICE USE DATE OF APPLICATION: /2 f ,30 0 JOB #: Do- 017 8'Z-o I RECEIPT #: ::J> 3: -l -l "" '" ::J>::J> ::0 -l :z: I'T1I'T1 C!J c-:J..# ("') 00.. -----------------------------------------------------------------------------~- .. n1C) (t) r-..J("')~ :c , t--lC"Jf:4I-"O rrl :I: lJJ 0 ;::0:0.........1. 0 uZO"tv.t:-- QCi')- 00 O"rT1c..not>.J """,,,,0.001-" l(oZ( ISSUED BY: j;lb~ )({ 'I TOTAL AMOUNT COLLECTED: