HomeMy WebLinkAboutPermit Backflow Test 2001-5-17
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I Job# 01-00503-01 I
Page 1 of2
TRANS#:01-0005416
DATE:11AY 17 2001
AMT RECD:2 $ 16.50
CHANGE:
CASHIER: 061
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CITY OF SPRINGFIELD, OREGON
COMMERCIAL PERMIT
City Of Springfield
Community Services Division
Building Safety
Job Number: 01-00503-01
225 North Fifth Street
Springfield, OR 97477
Office: 726-3759
Inspection Line: 726-3769
Location Of Proposed Site: 3444 main Sl Spr
Assessors Map#: 17023131
Lot: Block: Addition:
Tax Lot #: 00800
Subdivision:
*
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Owner:
Steve Thomsen
3444 Main Slreet
Phone Number:
City/State/Zip: Springfield, OR
New Value: $0
Address:
Scope Of Work: Backflow Device
backflow
Contractor Type
Plumbing Contr
Contractor
Twin Rivers Plumbing Inc
1525 Irving Rd, Eugene, OR 97404
Registration #
17695
Expiration Date
6/1/2002
Phone
541-688-1444
Office Use
Land Use: # Of Buildings:
Zoning Code: Occupancy Group:
Bedrooms: ATTENTION:Oregon law rE.Ij~i!t~5>>.!!!<;~:
Range: follow rules adopled by the ~~,IfL~9!!19";'
Notification Center. I nose rUlas are S81 lOHlI
To request an inspeclion call the 24 hour recording al:ir.~.:.~?9!!2~I~i.n~p'e<;ti9nslr~questedJbef6r'e'7:00
a.m. will be made the same working day, inspeclions (,evlW9.s\E1.<L'lf1!!.'i 76Q9..l~;'1]o~iULblllrnadeJhe. fojlowing
working day. calling the center. (Note: lhe telephone
R . tlr.I,'",hor It"r th'l Orpnnn Iltililv Notification
equlre nspec Ions.' 1 800 3r.2 2344)
t~,o,n',o,rl~ - - v - .
I Plumbinll I
-After device is inslalled but before backfilling trench.
Quad Area:
# Of Units:
Constr. Type:
Water Heater:
Backflow Device
Construction Types:
Occupancy Groups:
# Of Buildings:
# Of Bedrooms:
Handicap Access? 0
iArea (Sq. Feet)
I Main: Accessory:
# Of Stories: NOTICE: Height (feet):
Current Units: THIS PERMITPtWo~e'it'<iimG!F THE WORK
Census Code: DO~\J1!=!tll!Ppl\ED UNDER THIS PERMIT IS NOT
CmjMENCED OR IS ABANDONED FOR
Total: ...vl1RO DAY PERIOD.
Fee
Paid On Receipt#
Plumbinll
05/17/2001 5416
Value/Quantity
Fee Amount
Minimum Plumbing Permit Fee
$5.00
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Job# 01-00503-01 I
Paid On Receipt#
Plumbing
05/1712001 5416
05/17/2001 5416
05/17/2001 5416
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Fee
Slale Surcharge - Plumbing
Backflow Prevenlion Device
Adminislrative Fee - Plumbing
Total Plumbing
Grand Total
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Page 2 of 2
Value/Quantity
1
By signing lhis permillapplicalion, I agree 10 call for an inspeclion once the backflow prevention
device has been installed and is visible for inspeclion (726-3769). I also slale lhal all information on
this permit application is lrue and correct.
~~~
Signature
Fee Amount
$1,05
$10.00
$.45
$16.50
$16.50
s- II 7 /z-a, c> J
Date
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: '31.f-4-4- ~ J.;;t 'T~ ~
. ASSESSORS MAP #: )702-3/31 TAX LOT #: 008'00
O\INER: ~ d- ~ T~
ADDRESS: '3'lf'ltl' . /#.4(/1/
CITY: oS P,c2::,
5--r--
STATE:
PHONE #:
oL
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ZIP: '77'f7R'
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50
CONTRACTOR: 'I' ~ ~
ADDRESS: (S"2..5 ~
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7
PHONE #: (,88 - ( '+<+'-{-
ZIP: 17<t= 2-
EXPIRES: c., / Z-60 2-
/
CITY: ~ STATE: ~
CONSTRUCTION CONTRACTORS REGISTRATION #: i'7(Pq~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION ,
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE
c;; It 7/'ZPO, (
DAY;
FOR OFFICE USE
DATE OF APPLICATION: 051'7 al
RECEIPT #: 05/7 0 I ISSUED BY:
1: /~. ro
, JOB #: O/-Od s-o J -0 I
TOTAL AMOUNT COLLECTED:
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