HomeMy WebLinkAboutPermit Backflow Test 2009-3-27
225 FIITH STREET. SPRINGFIELD, OR 97477 . PH:(51J)726-3753 . FAX: (541)726-3689
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Tax Lot
Owner J)tJ flJ.p ht R.SeLL-
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Address he;- 35 Sn, ,~R7I
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BACKFLOW I)REVENTlON DEVICE PERMIT FE~: $67.86
Contractor Information
Contractor J(2?lJ:.s 'UkJ/tJ /l!#//U'/6/U/fNCE i h-s/O/2l9-hc'J~ $JJC \
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Addre~: ../?c3 l,g~ /j/J7/L/ Phone .5t1/-IA?y-f/q-?f?
City _ F LI ~.J~ "tate_D -e.... Zip tJ7c/ZJ c;..
Construction ,Contractors Registration # _
RO"<,9
Expires
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By signing this permit/application, I agree to call for an inspection once the backfIow prevention device
has been installed and is visible for inspection (726-3769). I also state that all information on this
permit/application is correct.
Signall)TE'
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DotE' 3-;:}'7-o9
For Office Use
Date of ApplicatioJ1
3/27/07
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Checked for Historical Status
--------
Checked for DelinquenciE'o
Shared Drive (T:)lBuilding FormslBackflow Prevention 7-08.doc
CITY OF SPRINGFIELD
Building/Combination Permit
Status
Issued
PERMIT NO: COM2009-00411
ISSUED: 03/27/2009
APPLIED: 03/27/2009
EXPIRES: 09/27/2009
VALUE:
225 Fifth Street, Spriugtield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 658 S 57TH ST SPACE 4
ASSESSOR'S PARCEL NO.: 1802040000200
Springfield TYPE OF WORK: Backllow Device
TYPE OF USE: Repair
Residential
PROJECT DESCRIPTION: Backllow Device
Owner: JOE AND LEE LIMITED
Address: PO BOX 717
SPRINGFIELD OR 97477
I CONTRACTOR INFORMA'~ION I
Contractor Type
Landscape
Contractor License
RODS LAWN MAINTENANCE & RESTORA18039
BUILDING INFORMATION I
Expiration Date
03/31/2009
Phone
541-689-4939
# of Units:
Primary. Occupancy Group:
Secondary Occupancy Group:
Primary Construction 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 GaragelCarport
Sq Ft Other:
Occupant Load:
nla
I DEVELOPMENT INFORMATION I
Fronfyard 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:.
....,...,.............,........ -
Notes:
NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK
'---r . ...~,~n T' "0 DCQ~~\T I~ ~lnT
AU ~ nunlLL-I.J l.1I 11 1-' ....... ....-
. -0 OR Ie ~p"i\lpnf'."'U ;'vi1 . ,
COMM~_[~C~., ",en ~,:,..J.~ ~Va'li1ation Descrintion
! :..',\1 -.e:'j fl<,\ \.,~.,,~I_,J.
, . ~ ". . .
$ Per Sq Ft Square Footage
or multiplier or Bid Amount
... . -... .~... ~"""":::1""" '........., . I' I 'j
I PUBLIC IMPROV~MElN31SI rules adopleq b'lth'" ()re(IQ;-' '.: ./
~~UllIIG?tlorSi(JafJhrk lhn~e. rules arH 3et fl)-11h
In OAR 952-uu 1-(jUJU ?;R'o'ugh OAR 952-001-
,0090. You iDo~nspoutslDpiins:if the rules by
calling the center. (Note: the telephone
number for the Oregon Utility Notification
Center is 1-800-332-2344).
Street Improvements:
Storm Sewer Available:
Special Instruction:
Description
Type of Construction
Value
Date Calculated
Paee 1 of 2
_~'ii'llIlf'1G.l!'IIll~.1:
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Status
Issued
CITY OF SPRINGFIELD'
Building/Combination Permit
PERMIT NO: COM2009-0041 I
ISSUED: 03/27/2009
APPLIED: 03/27/2009
EXPIRES:. 09/27/2009
VALUE:
225 Fifth Street, Springfield, OR
541-726_3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Total Valne of Project
Fpe~ Paid I
Fee Description
+ 12% State Surcharge
+ 5% Technol~gy Fee
Backflow Device
Miuimuml Adjustment Plumbiug
Amount Paid
Date Paid
$6.96
$2.90
$19.00
$39.00
3/27/09
3/27/09
3/27/09
3/27109
Receipt Number
3200900000000000]93
3200900000000000193
3200900000000000]93
3200900000000000]93
Total Amount Paid
$67.86
I Plan Reviews I
To Request an inspeetion 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.
IR,~9!!ired ln~'}ecti~,~J I
Backllow Device: Prior to covering aud provide a copy of the test report on site at the time of inspection.
By signature, 1 state aud agree, that I have carefully examined the completed applicatiou aud do ~ereby certify that all
information hereon is trne and correct, and I further certify that any and all work performed shall be done in accordauce with
the Ordinances of the City of Springfield 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.
I further agree to ensure that all required inspections are requested at the proper time, that each address is readable 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
times during construction.
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Owner or "~;ors Si;lature -
3/27/09
Date
Paee 2 of 2
City of Springfield Official Receipt
Development Services Department
Public Works Deparlment
225 Fifth Street
Sprin,gfieid,Oregon97477
541-726-3759 Phone
Job/Journal Number
COM2009-00411
COM2009_00411
COM2009-00411
COM2009-00411
Payments:
Type of Payment
CreditCard
cRcccintl
RECEIPT #:
3200900000000000193
Da te: 03/27/2009
11:19:32AM
Description
Backflow Device
Minimum/Adjustment Plumbing
+ 5% Technology Fee
+ 12% State Surcharge
Amount Due
19.00
39.00
2.90
6.96
$67.86
Paid By
JOHN OSTER
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
Amount Paid
njm
027148 In Person
Payment Total:
$67.86
$67.H6
027148
Page 1 of I
3/27/2009