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Permit Backflow Test 2000-5-17
. . I Job# 00-00741-01 I . Page 1 of2 M: '::;'65 MO, 5111-/00 ~: "/0. !!:x:) 8,?: 2/.-Af;- d Job Number: 00-00741-01 ~ ',.'SPRINQFIELD CITY OF SPRINGFIELD, OREGON COMMERCIAL PERMIT City Of Springfield Community Services Division Building Safety 225 North Fifth Street Springfield, OR 97477 Office: 726-3759 Inspection Line: 726-3769 Location Of Proposed Site: 4252 MAIN ST Spr Assessors Map#: 17023232 Lot: Block: Addition: Tax Lot #: 01802 Subdivision: ~ Owner: Howling Coyote Inc 525 Centennial Blvd Phone Number: 541-747-9047 City/State/Zip: Springfield, OR 97477 Alteration Value: $0 if' Address: Scope Of Work: Backftow Device Contractor Type Plumbing Contr NO.,." Registratio!~/S,~~~tion Date "iu,1-t. 'I'v1/,. <> CO,j,/, OAI<E:D "'1-/-41.1./2 541-484-9869 "1tv 'WE:tvC UtvOf, J(P/A~ 'r'80". 'tOOA,,, R"IiI.~,,!~7'Jr~,l' Office Use . t /J~A/'a- '1O'-4!vO '-/'fI1.1t,.I.<>' VIi/f 'D. O!vf, "!vO Quad Area: land Use: # Of Buildings: D~OR ,. # Of Units: Zoning Code: Occupancy Group: Constr. Type: Bedrooms: Heat Source: Water Heater: Range: Sq. Footage: To request an inspection call the 24 hour recording at 726-3769. AI) in~~#Cilq~~~te.qUested before 7:00 a.m. will be made the same working day, inspections requested after.?;,:00'a1mclW'illtbe,made the following . . ./ "/f)./ . ';)t, .. IUo'" . . working day. . Oo-r:, &ljlIO <lJ:,9/o Uf}IO .. . yo, !f',!!6H"'~ s&,rt~. 'tJ// .,';>.. i:lI.J'/.-. . Required Inspectlf?,!IS - "'II? - "U'I - 'Ne ...;. "4" .'/J9~ Sf} O.ll/l ~C;c ." ). -", I Plumbin!!' ~""I~Ofji:lJ InJ ;;;,~O . 1(",. ',_,.., "";',"} -After device is installed but before baCkfillinglfen~?I.JJ1q~./ ;., .~:. .. ,"'\ &/0" './ . J0. . . ""f-J Contractor Phone the Plumbing Works 1704 W. 6th POBOX 21407, Eugene, OR 97402 Backflow Device ,J..,. .J( Construction Types: Occupancy Groups: # Of Buildings: # Of Bedrooms: Handicap Access? 0 rArea (Sq. F. d) Main: Accessory: # Of Stories: Current Units: Census Code: Does not apply . Height (feet): Proposed Units: Total: Fee Paid On Receipt# Plumbin!! 05/17/2000 1765 Value/Quantity 1 Fee Amount Minimum Plumbing Permit Fee $5.00 . . Job# 00-00741-01 Paid On Receipt# Plumbing 05/17/2000 1765 05/17/2000 1765 05/17/2000 1765 <- Fee State Surcharge For Plumbing Permit Backflow Prevention Device Plumbing Administrative Fee Total Plumbing Grand Total Signature e Page 2 of2 Value/Quantity I 1 Date Fee Amount $1.05 $10.00 $.45 $16.50 $16.50 d~\ ~~c:.t ~p; ,(ceUice. .. . . BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET OPFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 ----------------q~~------------,--------------------------.----------------- JOB LOCATION: t.f-;:-~~ (\f\(i.: \^ . . . ASSESSORS MAP #: I ~Q ';\.");;).~-:l. TAX LOT #: () 180d OVNER: B.~~\~\^-~~ 0{)n:/\-1e LW". ADDRESS: .s1.S- 0e..v....'t~\A\A.L'6...\ 8luJ CITY: S'r -C-\.A. STATE: 0 YL PHONE #:_li:r ~ (j L/':::;', ZIP: 9.::; L/7:j BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.fo I CONTRACTOR: \ ~ -e.. \) h~_ \, ~ lA-fA U )/"\ rL ~ (' ADDRESS: 1':J-o 1./ Lv, (,-rt.. ~ 6 11'/ .liLt 6:t- - PHONE #: i-{?Lf 9 f?' ? CITY: rlA.~~e STATE: ()rL: ZIP: 'f7t.(6J CONSTRUCTION CONTRACTORS REGISTRATION 1I: :; 8' '::f :J. J... EXPIRES: [5 ~ / . 8/o.l0{ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE !HE 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. . 0~ - , ~ /~;{;tJ DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: RECEIPT II: TOTAL AMOUNT COLLECTED: JOll #: OO-OO~/-oi ISSUED BY: --------------------------------------------------------------------------------