HomeMy WebLinkAboutPermit Backflow Test 2009-4-17
225 FIfTH STREET. SPRINGFIELD, OR 97477 . PH:(54I)726-3753 . FAX: (541)726-3689
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BACK FLOW PREVENTION DEVICE PERMIT FEE: $67.86
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By signing this permit/application, I agreeto'call for an inspection on~e the backflow prevention device
has been inStalled and is visible for inspection (726-3769). I also state that all information on this
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Shared Drive (T:)IBuilding FormslBackflow Prevention 7..oS.doc
Status
Issued
CITY OF SPRINGFIELD'
Building/Combination Permit
PERMIT NO: COM2009-00517
ISSUED: 04/17/2009
APPLIED: 04/17/2009
EXPIRES: 10/17/2009
VALUE:
225 Fifth Street, Springtield, OR
541,726,3753 Phone
541,726-3676 Fax
541-726-37691nspection Line
SITE ADDRESS: 1072 LAUREL AVE
ASSESSOR'S PARCEL NO.: 1802061309207
Springtield TYPE OF WORK: Backf10w Device
TYPE OF USE: New
Residential
PROJECT DESCRIPTION: Backf10w device
Owner: NEVIN AMY F & THOMAS M
Address: 1072 LAUREL AVE
SPRINGFIELD OR 97478
Phone Nnmber: 541-746,7639
I CONTRACTOR INFORMATION I
Contractor
OWNER
TENTION' Oregort lOOIEDlNG.iNlioRMATlON I
AT . d Y;' \' U I. I 'T~-
, '. 101l0W rules adopte ds~ -jle.~are. set lort~
# ot Umts. . T alion Center. Th \I ~1. ~(fP5~'2,001
Primary Occupancy Gr~~~ 952-~'ll-001 0 throu~~ie tIll! ~t",s1lD'fe
Secoudary Occupancy d.?ml!l: 'Iou may obtall1 COi~T !l~ Ybl~~~tlne
Primary Coustruction T~P8allil1g the'tBl1ter. (N~ e i\\\f'N1i.Yii<:;atlOn
Secondary Construction Tn'lIliiber lor the.Orego 0,3 !jgS41lrpe:
# of Bedrooms: . Center IS 1,80 ~nergy Path:
Sprinkled Building:
Contractor Type
Laudscape
License
Expiration Date Phone
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2ud Floor:
Sq Ft Basemeut:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
n/a
I DEVELOPMENT INFORMATION I
REQUIRED PARKING
Front yard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot coverage:1'\'C 'tlO~t
\,In,.,Ct', .. ~J"" ~?'?~~~~~''T \S t\O't
1\-\IS P~P'ti~~t 'iwtRm<- J '" Ol\
U1\-\~1 f\}\'1 ~A~
t' \lJ\C\'~CH) o?> :lOU Sidewalk Type:
CO\lJ\ .. 00 UJ\'i pc?>1 . DownspoutslDrains:
J\~'i 10
Total:
Handicapped:
Compact:
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
f
,
I Valuation Descriotion I
Description
Type of Construction
$ Per Sq Ft
or multiplier
Square Fuotage
or Bid Amount
Value
Date Calculated
Page I of 2
CITY OF SPRINGFIELD
Building/Combination Permit
Status
Issued
PERMIT NO: COM2009-00517
ISSUED: ,04/17/2009
APPLIED: 04/17/2009
EXPIRES: 10/17/2009
VALUE:
225 Fifth Street, Springfield, OR
541,726-3753 Phone
541,726-3676 Fax
541-726-3769 Inspection Line
Total Value of Project
F~e.s P~I~
Fce Description
+. 12% State Surcharge
+. 5% Technology Fee
Backllow Device
Minimum/Adjustmentl'lumbing
Amount Paid
Date Paid
Receipt Number
$6.96
$2.90
$19.00
$39.00
4/17/09
4/17/09
4/17109
4/17/09
2200900000000000400
2200900000000000400
2200900000000000400
2200900000000000400
Total Amouut Paid
$67.86
, 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, Reouired Insneetions ,
Backllow Device: Prior to covering and provide a copy of the test report on site at the time of inspection.
By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance 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.
1 further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project.
1 fnrthcr agree to ensure that all required inspections are requested at the proper time, that each address is readable from the
street, that the pe,~mit card is located at the front of the property, and the approved set of plans will remain on the site at all
timeSduringC(~~Uj~on'~fxW ~I /1 1/rll
I ' '/ 'f
Owner or Contracto~ignature Date
Page 2 of 2
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
City of Springfield Official Receipt
Development Services Department
Public Works Department,
Job/Journal Number
COM2009,005 17
COM2009,00517
COM2009-00517
COM2009-00517
Payments:
Type of Payment
Credit Card
cRe:ccintJ
RECEIPT #:
2200900000000000400
Date: 04/17/2009
Description
Backllow Device
Minimum/Adjustment Plumbing
+ 5% Technology Fee
+ 12% State Surcharge
Paid By
AMY NEVIN
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
djb
o 1793b In Person
Payment Total:
Page I of I
II: 19:43AM
Amount Due
19,00
39,00
2.90
6,96
$67,86
Amount Paid
$67.86
$67,86
4/17/2009