HomeMy WebLinkAboutPermit Backflow Test 2009-3-10
Status
Issued
. CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2009-00323
ISSUED: 03/1012009
APPLIED: 03/1012009
EXPIRES: 09/10/2009
VALUE:
225 Fifth Street, Springlield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 2750 VILLA WAY
ASSESSOR'S PARCEL NO.: 1703233300203
Springlield TYPE OF WORK: Backllow Device
TYPE OF USE: New
Residential
PROJECT DESCRIPTION: Backllow permit
Owner: MONTGOMERY THOMAS R & S K
Address: 2750 VILLA WAY
SPRINGFIELD OR 97477
Contractor Type
Landscape
I CONTRACTOR INFORMATION'
Contractor License
SCHELSKYS LANDSCAPE AND IRRIGATI 12170,6330
BUILDING INFORMATION I
Expiration Date
02/28/2010 '
Phone
541-744-7135
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Constrnction Type
Secondary Construction Type:
# of Bedrooms:
# 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:
n/a
I DEVELOPMENT INFORMATION'
Front yard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
REQUIRED PARKING
Total:
Handicapped:
Compact:
I PUBLIC IMPROVEM~NTS'
Street Improvements: , AlnTle. Sidewalk Type:
I w requires yOUiIJi). .E.
Storm Sewer AXl1i!'!!!(e::\ON: Ore~on _ a he Oregon LT~f~ PERM Downspouts/Drains:
Speciallnsh:uqu~n;'V rules adopled I"y t, les ai'e seA. ~'l~. IT SHALL EXPIRE IF THE WORK
Notification Center. Those rUh OAR 95~' ~1_0RIZED UNDER THIS PERMIT IS NOT
Notes: in OAR 952.001-0010 througes of \118 r I ~\~yIENCED OR IS ABANDONED FOR
Y obtain cop' - IV.180 .
0090. You ma . "'~'^' thp ("leD fie DAY PERIOn
Calling lilt: vv'"'''''' ,- ,..' ..,,--....""....
h Oregon Ultl!l~ "v""----. I
number~~~;ereiS 1-800-332 _Y<aluation Descri'ltion
$ Per Sq Ft Sq uare Footage
or multiplier or Bid Amount
Description
Type of Construction
Value
Date Calculated
Pa~e 1 of 2
CITY OF SPRINGFIELD
Building/Combination Permit
Status
Issued
PERMIT NO: COM2009-00323
ISSUED: 03/10/2009
APPLIED: 03/10/2009
EXPIRES: 09/10/2009
VALUE:
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Total Value 01' Project
rees Paid'
Fee Description
+ 12% State Surcharge
+ 5% Technology Fee
Backllow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
Receipt Number
$6.96
$2.90
$19.00
$39:00
3/10/09
3/10/09
3/10/09
3/10/09
2200900000000000245
2200900000000000245
2200900000000000245
2200900000000000245
Total Amount Paid
$67.86
I Plan Reviews ,I
To Request an inspection call the 24 hour recording at 726-3769. All inspections 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.
I .R~,Il,ui.red Jnsnec.ti~ns'
Backllow Device: Prior to coveriug and provide a copy of the test report au site at the time of inspection.
By signature, I state and agree, that [ have carefnlly examined the completed application and do hereby certify that all
information hereon is true and correct, and.! further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springlield and the Laws of the State. of Oregon pertaining to the work described herein, and
that NO OCCUPANCY will be made of any 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.
] further agree to ensure that all required inspections are requested at tlie proper time, that each address is read~ble 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
~.r~~constru>~. . ~.Sjlo/~oo~
Owner or Contractors Signature~ Date
Pa~e 2 of 2
225 FIITH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689
~j . (!C?- 3:13 . .,'
~\ City Job Number
~ "1-7'
"~' 0/ /SO
t,_';, Job Locatirm
~J
~) Assessors Mor
'"'rJ;
'-~~I~ Owner --;OM f k411..,
~
~- 1 Addres<
~:
~f//I
l;_~
. .J, 'T--f,.;
~i
~1
~i
~j
(ll);J
~\~~j
~i
6,
...:1
.l!l'r~l~
">
~.
IfE'\
~'l
~.--~
~~
e;>.)
.~",=I~
1;_'-'
~l
~;
~
(1ll),l
t, -:
~~
Q\, .~
~~
~. -,.
,.
?""
~
.~
~j
~~
~~
.,.._..J~
~J""1
~f/
~{
.:0 '--'"
~l
?/cdrN Pcur
Tax Lot
4."-I",.,,,~~,^"7
~ ,
'2-i50
tJ, '{i~
iAJ.....,
,
Phorf'
Cit:'
St~tp
OIL
Zip
'17.1/77
BACK FLOW PREVENTION DEVICE PERMIT FEE: $67.86
Conyacrorlnformailon
Contractor ~ LI -
5c~<- f5~ 'r !,;-
.t!,u<A.J::;-c..qp "" I'ro",\.hp,,- ..z-;z,c,
,
Addre~, PO, !So/( 711-5
E":J '
Phol'f'
'71fcf- 7/?5"
oR..
7ip
P7r<D/
Statp
City
Construction Contractors Registration # '
653 ()
Expire< Z- -;;t. ;:'-/0
By signing this permit/application, 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 correct.
Signatl'Tf'
~
~-
.-C/
Dof' pya?'
For Office Use
~
Date of Application
2~/O-07
AJ . rv----
Checked for Delinquencif'<
---------/
Checked for Historical Status
.~
Shared Drive (T:)JBuilding FormslBackflow Prevention '7-08.doc
City of Springfield Official Receipt
Development Services Department
Public Works DCPl!rtment
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2009-00323
COM2009-00323
COM2009-00323
COM2009-00323
Payments:
Type of P"yment
CreditCard
cReccintl
RECEIPT #:
2200900000000000245
Date: 03/10/2009
II :40:40AM
Description
Backtlow Device
Minimnml Adjustment Plumbing
+ 5% Technology Fee
+ 12% State Surcharge
Am-aunt Due
19.00
39,00
2.90
6.96
$67,86
Paid By
DARREN SCHLESKY
Item Total:
L'heck Number Authorization'
. Received By Batch Number Number How Received
Amount Paid
nJm
057881 In Person
Payment Total:
$67.86
$67.86
(
Page I of I
3/1 0/2009