HomeMy WebLinkAboutPermit Plumbing 2009-10-14
Plumbing Permit Application
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I permitno( :q --()/5Yj I.
I Date: /O/IL(!(Yj I
This permit is issued under OAR 918-780-0060. Permits are issued only to the person or contractor doing the work. Permits
expire if work is not started within 180 days of issuance or if work is suspended for 180 days.
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I Zon,'ng approval verl'fied? DYes D No I 1..h,m......Wt"..',"..:i.~~."."I".7..',.."";rh."<....<z"'''''.';'''''''''1''''''''.';'1 ,....CoS'...f'PI..'1 Tof. iiP'lj
I~Descrip.-tion't'J:k.. ~~1f;)(~~~~:~?~r<<f{{vi' Qty'.: ir~~.... -'Ji.~~~ ~i:~"- -. ..A~
i\fl~~J.':~.ii.:~t"o..;'*r.,.'r....~iP x-.;.y;.ij!~<?.,,~~~t'I~..':;.~~~cg ti:...1:.~...e: ~~::.e:~;t~i!fi ~'.~~9.~~.:.'Ji;;
I Sanitation approval verified? DYes D No I I New residential I
I D Reside~ti~IATEGOIRD~~~~~~~:~TRUClTDIO;o:mercial" II )obOJ.~~~r;;;a~~;5~:;e~~f~~:.T!s;st
bibs, ice maker, under floor low-point $238.00 $
;:;~i:il~TojClBi:SlmE'.INf;()RMAtION;kAN01~lf()GAT:I()N~g~i~{1 drains and rain-drain packages)
Job site address: L./? ~ C-~ Nt; #/~ ( I 2 bathrooms/I kitchen $374,00
I ,,h ;1.1 I II?V I ,?1/J I 3 bathrooms/I kitchen $439.00
'1 ~~~;:r~1J{~15~U;~/<-, Taxl~:t&D : ::~~:::::::~:::~~;~~70~~:~r)3) I ~:::~~
~{i'&~~~O:;~~~~'t'.RK_'~ll_fi i ~i?':::::::," (;""'0 .,,, '";'::,~:
I :::" /",,,,.;y'.; :,,1.... "PRORER:rY,10WNER'lnf;iJ;jj)1~.i'i~:1'i:~~~'i(if\~ I 3,601 to 7.200 square feet $174.00
I'Name:fcr~Nc. C/j:ISl'i;"1/( C(I><.I-c-1. 117,20lsquarefeetandgreater $232,00
". I Manufactured dwellin~ or pre-fab (circle one)
I Address II / b L eN r~1II /a... / I I Connectionst~buildingsewerand I I $58,00 I $
I City: S;t~ I State: 61< I ZIP: t'?Y77 I water supply ,
I Commercial, industrial, and dwellings other than one- or
I Phone: . - I Fax: I two-family
I E-mail: 1 I Minimum fee I I $58,00 I $
I Each fixture $19,00 $
This installation is being made on residential or farm property
owned by me or a member of my immediate family, and is I Miscellaneous fees
exempt from licensing requirements under OAR 9] 8-695-0020. 1100' storm, sewer, water line
Signature: I Each fixture, appurtenance, and piping
I ".CONTRACT:0R"INSTALLAT:ION.'"::".,,Ai.,.:;. ....'., I Storm water retention/detention facility
I Business name: ~ e n / / . -.p. /J Irrigation systems
11/ eX- L II/'Mf "'" ~N"".rc"",_ p" , d '
n /' Iplng or private storm ramage
I Address: ? O. j<-/ <;> Y b f r I svstems exceeding the first 100 feet
I City: S f} J l State: 0 -f' I ZIP: '7 ;; V //,I Specialty fixtures .
I P" b 7 rl"" I 7 r/ {/73 I RemspectJon (no. ofhrs, x fee per hr.)
Phone: 7 7{ - '1 I/> Fax: -)' {;) J I Special requested inspections (no. of
I E-mail: hrs. x fee per hr.)
I tCB license no,: 'J / / 1f I BCD license no.: I Each additional inspection: (]) $58,00 $
! Plumbing license n~.: l~ij~'i~~;g~~~Sfprjmf~~1i.rfi~ M~nimum fee 's;/~J I
I Print name: I~ e'/ (J.::> ~ I I Enter\;alueofinstallation and equipment $_: -~J(;O
IV rA/.- ,/et.,f _ I I -Y,
I Signature: ry C-, ~ __ I ~_~:; :e~ b~~~~.n inst~~~_~~~~_.~~.dT;_~~lme~~.v:I.ue~._.: ~ .~~--J
- ~ - .d-1~i;;;)lm.~.~~I?IilI.HC~NTg:,l:lSEL~,-,~~~1 0
I (A) Enter subtotal of above fees I Cf>': P
(Minimum Permit Fee $58.00) $0:J' I
I (B) Investigativefee (equal to [A]) I $_) ~ ty U
I (C)EnterI2%surcharge(.12x[A+B]) I $ (" Ay:'
I (D) Technology Fee (5% of [A]) $ _ I~"
I TOTAL fees and surcharges (A through D): I $ &' /, .Ii V
SPRINGFIELD ~ .
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ria.. ~
225 Fifth Slreel . Springfield, OR 97477 . PH(54t)726-3753 . FAX(54t)726-J689
~
$> ~~-0
440-2500-J (I t/08/COM)
$76,00
$19.00
$19,00
$19.00
$19.00
$19,00
$58,00
$58.00
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Status
Issued
CITY OF SPRINGFIELD'
Building/Combination Permit
PERMIT NO: COM2009-01S09
ISSUED: 10/14/2009
APPLIED: 10/1412009
EXPIRES: 04/1412010
VALUE:
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541- 726-37691nspection Line
SITE ADDRESS: 1176 CENTENNIAL BLVD
ASSESSOR'S PARCEL NO.: 1703264411000
Springfield TYPE OF WORK: Backllow Device
TYPE OF USE: New
Commercial
PROJECT DESCRIPTION: Backflow Device
Owner: CHRISTIAN SCIENCE SOCIETY
Address: 1176 CEN'fENNIAL BLVD
SPRINGFIELD OR '97477
I CONTRACTOR INFORMATION I
Contractor Type
Landscape
Contractor
MEDALLION LANDSCAPE SERVICE INC
License
7118
Expiration Date
02/28/2010
Phone
541-933-2745
. BUILDING INFOR~A TlON I
# 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 2Dd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
n/a
I DEVELOPMENT INFORMATION'
Frontyard Setback:
Side 1 Setback: .
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
0/0 of Lot Coverage:
REQUIRED PARKING'
Total:
Handicapped:
. Compact:
~
I PUBLIC IMPROVEMENTS I
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
NOTICE:
TUIC' n"n~'IT ["I"' L E"-IY- ,-
- -. ...1 e'i, ,... i.~ .. .J:,.......J....= .:.:~.t1:\
'. AUTHORIZED UNDER ~H\ZnRatMlf IfeIDTntion I
, COMMENCED OR IS AfiAiVljUI~tu ~UK
T~~~' 0}rg),,RfI'(;RfJ.I100, $ Per S,q ~t Squa.re Footage
, or multIplier or BId Amount
Sidewalk Type:
4ITENTION:.or~~n law requires you to
fo'1l'bm8fW~l:lIi' by the Oregon Utility
Notification Center, Those rules are set forth
In OAR 952-001-0010 through OAR 952-001-
0090. You may obtain copies of the rules by
':llIlinn II''' rJ"~r. (Note: the tele~hone
number for the Oregon Utility NOlllicatlon
Center is1-B00-332-2344).
Description
Value
Date Calculated
Page 1 of2
Status
Issued, .
225 Fifth Street, Springfield, OR
541"726-3753 Phone
541-726"3676 Fax
541-726-37691nspection Line
'" . f
Total Value of Project
Fees Paid'
Fee Description
+ 12% State Surcharge
+ 5% Technology Fee
Backflow Device
Miuimum/Adjustment Plumbing
Amount Paid
$6.96
$2.90
$19.00
$39.00
Total Amount Paid
$67.86
I Plan Reviews I
Date Paid
CITYiOF SPRINGFIELD
Building/Combination Permit
"
PERMIT NO: COM2009-01S09
ISSUED: 10/14/2009
APPLIED: 10/14/2009
EXPIRES: 04/1412010
VALUE:
10/14/09
10/14/09
10/14/09
10/14/09
ReceiJt Number
1200900000000001143
1200900000000001143
1200900000000001143
1200900000060001143
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.
, R~'lIIired Insnections 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 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.
I further certify that only contractors and employees who are in compliance with ORS 701.005 wili he used on this project.
I further agree to ensure that all reqnired inspections are requested at the proper time, that each address is readahle 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. :? '
, /
)~--- (~~
,
Owner or Contractors Signature
Pal!e 2 of2
Date
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2009-0 1509
COM2009-0 1509
COM2009-01509
COM2009-0 1509
Payments:
Type of Payment
CreditCard
cReceint 1
RECEIPT #:
City of Springfield Official Receipt
Development Services Department
Public Works Department
1200900000000001143
Date: 10/14/2009
9:56:56AM
Item Total:
<":h~ck Number Authorization
Received By Batch Number Number How Received
Amount Due
19,00
39,00
2.90
6,96
$67.86
Description
Backflow Device
Minimum/Adjustment Plumbing
+ 5% Technology Fee
+ 12% State Surcharge
Paid By
KENNETH CORNELLlNG
Amount Paid
njm
56727 In P,erson
Payment Total:
$67,86
$67,86
i'
Page I of 1
10/14/2009