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HomeMy WebLinkAboutPermit Backflow Test 2000-7-18 ," . " . . SPRINGFIELD BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION ~ 225 FIFTH STREET OFFICE: 726-3759 " SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 :::-::::~:::~----~~~---~~~~-~J~--~~~~-~f\~----------------------- " ASSESSORS MAP 1I: ) 70 J Z J L( <- OVNER: ~ l\\t;tl( r/hMIf ''S~lrt\ p( -S \'.(;~o TAX LOT 1I: c::> s-go-o CITY: STATE: PHONE 1I: ().(k c.- ZIP: ADDRESS: BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 CONTRACTOR: fti.o:D!-i\ QJ~I:J ~12i gfrflfJtV ADDRESS: ~ -q~ H~p . PHONE 1I:_fA?fi.- tal CITY: f) 7~ J . . STATE: fJtJ ZIP: q0Lp7.".... CONSTRUCTION CONTRACTORS REGISTRATION 1I: \ 7..Z-.f;2, EXPIRES: Z - z.J?..-(j I BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. . . Qt~g~,lr SIGNATURE . ~v /3--QJ OATE FOR OFFICE USE -------------------------------------------------------------------------------- RECEIPT 1I: JOB lI:Do-01i1 g-O{ :0 :x ..... .....355:5 ;:0 ..... Z ,.." I"Tl (J) n..# ("') oc...... D .. c:o 00 "'-Jr-....... ____________________________________________________________________________~- I ~("')fflI__'i.O rr1 ::c CD (;:) :::rJDI-'- 10 "ZO'I',)I',) OCil- cO"- O"rTlUlOO ~..ooco 07 l!SoD 2-00 8" ISSUED BY: )vi? DATE OF APPLICATION: TOTAL AMOUNT COLLECTED: //,SO . I Job# 00-01118-01 I . Page 1 of 2 TRANS#:01-0002608 DATE:JUL 18 2000 AMT RECD:2 $ 16.50 CHANGE: CASHIER: 061 CITY OF SPRINGFIELD, OREGON RESIDENTIAL PERMIT City Of Springfield Community Services Division Building Safety Job Number: 00-01118-01 225 North Fifth Street Springfield, OR 97477 Office: 726-3759 Inspection Line: 726-3769 Location Of Proposed Site: 862 Mckenzie Crest Dr Spr Assessors Map#: 17032343 Lot: Block: Addition: 2nd Tax Lot #: 05800 Subdivision: River Glen Owner: Rodney Chase 708 blackstone st Phone Number: 541-746-6973 City/StatelZip: springfield, OR 97478 New Value: $0 Address: Scope Of Work: Backflow Device backflow Contractor Type Landscape Contractor Hidden rivers irrigation 3487 hawthorne, eugene, OR 97402 Registration # Expiration Date Phone 541-688-1131 Office Use ATfb\i I !UI~:UI d<i"! .a.i ":;Cjulre,} j.Ju h. Land Use: follow ru'e:#;OfIBuildlngs:; r.r::por Utility Zoning Code: Not'fi,:" 'Oi::i::~paiti:y Gro~p: DweiliMg>"\i, Bedrooms: 'n 0,..,-, <.~.:- Heat-Source: '.. d,",.; ...~-\]iJi' 0090 Y'lll r~\1 ro"''''' I -". ." 0 ,.. '1,'05 b) Range: . -, Sq. Footage':' '",,~, ...~:Ii.... . ..H' ... '",.:"\~1e . ""mhp-rlor l'h-~ () ',~C1fl:1 Uii:i;". l\'otificatior. To request an inspection call the 24 hour recording at 726-3769. All inspeclions requestea before.7:00,.",) a.m. will be made the same working day, inspections requested after 7:00 a.m. ~iIFbir;nade Hie 'foilowiri'g' . working day. Quad Area: # Of Units: Constr. Type: Water Heater: 1 (VN) Wood Frame Backflow Device Required Inspections I Plumbing I -After device is installed but before backfilling trench. Construction Types:(VN) Wood Frame Occupancy Groups:Dwelli[lg # Of Buildings: # Of Bedrooms: Handicap Access? D rArea (Sq. Feet) Main: Accessory: Store NOTICE: THIS PERMIT SHALL EXPIRE IFTHE WORK AUTHOR/ZED UNDER THIS PERMIT IS NOT H7R~A~~~~~D OR /S ABANDONED FOR ~ ~IV . Q" '" . v'''''''''IOD ProposedIUmts:1' . . - # Of Stories: Current Units: Census Code: Does not apply Total: Fee Paid On Receipt# Plumbing 07/18/2000 2608 Value/Quantity Fee Amount Minimum Plumbing Permit Fee $5.00 . . . Job# 00-01118-01 I Paid On Receipt# Plumbing 07/18/2000 2608 07/18/2000 2608 07/18/2000 2608 . Page 2 of 2 Value/Quantity Fee Amount I Fee State Surcharge For Plumbing Permit Backflow Prevention Device Plumbing Administrative Fee Total Plumbing Grand Total 1 $1.05 $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 thisper~Cr~is~ ~---l&-w Signature Date