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Home My WebLink AboutPermit Backflow Test 2009-4-22 ',:.:-~" .::i;;:'"" _ r.~ '._ ~,...._. =;\ "i::-- __" .,"-,"'. '."-.!c j:', _"~' J. ....~ '. '.' ~,":,,'l';,,' GIT:Y,OE'<;:'~GF1ELD'-OREGON . _'~. ..','. l,~' .. ",' "'" -~, , ~1>:1 - ,'?:~- 1.1'.'". . ,'>(iJ~ '. ''''. i1 C ~~:.e.,>,_ ,~~."'" - :;!,,,,.tft. ..1.. ~.~.~''''1Ji -" J"7c. r'"" ~"" ~. ,-:e'~ fr. ..~-.~ ~ .". ~.~.'" ,~' SP~ ',;~* "JI-;',"",~.s; ';:::~ ~,...;:i~, d&A "'!~.:, .'::f~)m~~~ ~J11 '. 'q 225 FlITH STREET. SPRINGFIELD, OR 97477 . PH:(54I)726.3753 . FAX: (541)726-3689 ~! ~i ~~ 0,:, '-r--h l~:' ~J" ~i .~. . 'r-:-J~ ,_ 1" ~~I~ ~ <;' I~_~., "~:.1 r- ~ ~- i caJ f;'I\'-~ ~~ ~' II l. I r6) .~ T'r=l~ ~, ~ f?'..l ~" ~~ -. OJ .~, 'T-=I~ I, '>; ~i ~4 ~ ~" ~) ~~ f.!'i\ " ~1 ~ ~ rll~j~ ~; '(1:)) ~, ... J ~l C 9-2527 City Job Nnmber OVVl ZOO , Job Location J b,'? 7J/oy'eVl 5,} - c?~ /C j ~/7/"~;'f;;; Ir/ Assessors M~p \ flO'21 (J/f({)_ Tax Lot (If!!:.f:,{!;:t) OwnerL=:..,~",- 4,/ .// Addres.J 6 ~ y 4, // o"e ~ City y;' :;>!'/ p !/ ~,,_~~/k ?;'fl-://pn /.?//;!;~ /2-/ Stot,. /":) J(' PhoD" 77'7 oJ67 Zip 9- 7'1 7 '7 BACK FLOW PREVENTION I>EVICE PERMIT FEE: $67.86 COlltractor IlIformation Contractor -<::7 / ~ / r/,o /" Addre,s ? ~ \' '7 d,_~ cL City ~ r-:!7r,: jj 6rJl.e V/. /2./ rState o/e. - ' Construction Contractors Registration # _ c Pho,," '? ,,/,y 0 s 6 :7 Zip ;;: 7'9/7 Expires -. ....-... ~- ....-... 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. Signatur~~-'" / /LL-4 ~(~/#~~ For Office Use Date of Application flb)./o 1 Checked for Delinquencip< ----..-" D?t,. Y /Z/c7 Z/. ~ i.~ --------~ Checked for Historical Status ~- Shared Drive (T:}fBuilding FormslBackflow Prevention 7..QS.doc CITY OF SPRINGFIELD Building/Combination Permit Status Issued PERMIT NO: COM2009-00527 ISSUED: 04/22/2009 APPLIED: 04/21/2009 EXPIRES: 10/2212009 VALUE: 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 3639 HAYDEN BRIDGE RD ASSESSOR'S PARCEL NO.: 1702194205500 Springfield TYPE OF WORK: Backflow Device" TYPE OF USE: New Residential PROJECT DESCRIPTION: Backflow Deice Owner: TORKELSON MICHELLE A Address: 3639 HAYDEN BRIDGE RD SPRINGFIELD OR 97477 I CONTRACTOR INFORMATION I Contractor Type Plumbing Contractor OWNER License Expiration Date Phone BUILDING INFORMA nON I # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Constrnction Type Secondary Construction Type: # of Bedrooms: # of Stories: Height of Structure Type of Heat: Watei'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 I 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: Street Improvements: p,TTFNTION' Orp.n!'>n lAW rp.mlir,," vnll In I PUBLIC IMPROVEMENTS'I" rules adopted by the Oregon Utility , " ,ation Center. Those rules are set forth in OAR 95~ide\Valk:;rype:'ugh OAR 952-001- 0090. You D!YIav obtain /DNlD;,gS of the rules by II' ownspouts rams: ca Ing tHe (Jelled'. \mll~. lIle telephone number for the Oregon Utility Notification Center is 1-800-332-2344). Storm Se"l"rn\.yfli)ll~le: S . II .U1.,.!- pecla nstructlOn:'. I HIS PERMIT SHAL ' Notes: ~\UTl10RIZED UNDE~ EXPIRE IF THE WORK ,OMMFAlrcn,,~._ THIS PERMIT 1.<:: W1T V\' J 8n -" 'u /iDAIWONE- ! c D,W PERIOD, -1\~~I~ation Descriotion I Description Type of Construction $ Per Sq Ft or multiplier Square Footage or Bid Amount Value Date Calculated Pa2e I of 2 Status Issued CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2009-00527 ISSUED: 04/2212009 APPLIED: 0412112009 EXPIRES: 10/22/2009 VALUE: 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line Total Value of Project Fees PaW Fee Description + 12% State Surcharge + 5% Technology Fee Backflow Device Minimnm/Adjustment Plumbing Amount Paid Date Paid, Receipt Number $6.96 $2.90 $19.00 $39.00 4/22/09 4/22/09 4/22/09 4/22/09 3200900000000000261 3200900000000000261 3200900000000000261 3200900000000000261 Total Amonnt Paid $67.86 I Plan Reviews 1 To Request an inspection call the 24 hour reeording 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 Reo\lir,~~ 1ns\,~.e~i~n~ I Backflow 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 1 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 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, Bnilding Safety. I further certify that only contractors and employees who are in cumpliance with ORS 701.005 will be used on this project. I fnrther agree to ensure that all required inspections are reqnested at the proper lime, thal'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. '/// A~~P/ //~/' ~, ~/. 09 6.Wtr~r Contractors SignatV Date Pa2e 2 01'2 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone City of Springfield Official Reeeipt Development Serviees Department, Publie Works Department Job/Journal Number COM2009-00527 COM2009-00527 COM2009-00527 COM2009-00527 Payments: Type of Payment Check cReccintl RECEIPT #: 3200900000000000261 Date: 04122/2009 Description BackOow Device Minimum/Adjustment Plumbing + 5% Technology Fee + 12% State Surcharge Paid By L.R. HAY Item Total: Check Number Authorization Received By Batch Number Number How Received 1276 In Person Payment Total: njm Page I of I 10:11:30AM Amount Due 19,00 39,00 2,90 6,96 $67.H6 Amount Paid $67.86 $67.86 4/22/2009