HomeMy WebLinkAboutPermit Backflow Test 2002-9-30
22B FIrfH STREET. SrRINGrn:LD, OR 97477 . rH:(B41)726-37B3 . FAX: (B41)726-3689
~
~
"1'I'!"'l1
~
~
~ Assessors M1 r
..~
'. Ii
~1 Owner
~ 4 Addres<
l~
""e
~
~
~
..~
~
~
Cd1
~
..~
~
i
~
~
~~
t"
r--
~
~
~
~
~
m
.
-
CITY OF SPRlNGFIELD, OREGON
TRANS#;01-0010~5~
DATE:SEP 30 200~
At1T RECD: 2 $ 51. '75
CHANGE:
CASHIER:061 I
City Job Number 6Z-o ) I b 9-01
Job Locatior f!e/J:5 1-1 Mf IJ(Ijerq.;uN
,
!/fOz..O); z- r
~d
Tax Lo'
08"8'0 ~
City
'[:bel S k-Orz.. TE
fJ,2,.1 Y'v\ r, ve-PJD rJ
SFt1fJ~F{~
Zip
Cf7V 78"
Phon"
Df-
Stat"
BACKFLOW PERMIT IS $51.75 (includes Permit Fee, State Surcharge & Administrative Fee)
Contractor Information
Contractor
G fLPrN '\ IS lANP S (A(J({ SuG.
Addrers P,o, BO-l '2.,.,v,
Phon~ 7~(P -?c3 Y
State Of!- ZiIL: ~n cr7l/7.r
""o,IlI\es l \}~\'i\\'i
/02- S:-~!>.tlo'(\Ia.':':,;O\':;E1~iresiO\\i'O '{ ;)00 V
_..,"t''.U\,-o'' ..'),",rI.U'~.' ..\,..~a'(;':' ";,,~nu\ .
~\ I....: c'J ;';l'~..,: '{\,05'" ,- 01\\'\ ,,~. ^f> '0';
_ \0'" ,Ill ,-",,,Ie(. 'n' :l1l1J~ \~s llll.,
'\V\ ,1:"_0\1" -,' ('\0'\0\\ . -:"C- o~ 'i';o\\2
By signing this permit/application, I agree to'ca:ijifgr.ari'ih;~pe~tioil'oft~~the:bar1Z'flow.rp?evention
. . . .. . n'~:\ \ - . ,...f '.JIJ~ .':\.\~\:;). ~ . ,....\:'h"\.... .
devIse has been Installed and IS vIsIble for Insp~S!lOn:67Q6~3_l~~)." I'als<Q~.tate tlia~ all InformatIOn on
h' 't/ I' , , . "U. ", ' e!'\on 0,;.'-'.1
t IS perml app IcatIon IS correct ,,~ "1IIi';' .. .'(\" 1)\ ., ,,""?"" .
L ~Q ~)~\J3(':'(':: ,...'""
.- - -'-
City
SQpU).
Construction Contractors Registration #
Signatun'
:"l~~'f..
Oat" ~ ,<t~\\a'~z....
~\, t.i-\l~~~~~~ 't(J~
.t''5.\Cf;;. .~\\ S\\~~~~ \~,~'U(J~~
For Office ~~\S \l;~~it.~ \)~~ \S :-:"
\>-\~i\ ~,- x.~'"'~':> \l't.\"-
C.\)~~'O\) 'U~
l'~"
Date of Application
cJ73.0 0 z
~/
.
L../'
------
Checked for Delinquenci".
Checked for Historical Statu.
ShaR:d Drive CT:)lBuilding FormslBackflow Preventionl.o2.doc
.
.
-
City of Springfield
Plumbing Permit
Status: Issued
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 4321 MT VERNON RD
ASSESSOR'S PARCEL NO.: 1802052108803
PERMIT NO,: PLM2002-00100
ISSUED: 10/4/2002
APPLIED: 10/4/2002
EXPIRES: 4/4/2003
Springfield
PROJECT DESCRIPTION: Install Backflow Device
TYPE OF WORK:
TYPE OF USE:
New
Residential
OWNER/APPLICANT:
KORTE DORIS ELAINE
4321 MT VERNON RD
SPRINGFIELD OR 97478
PLUMBING CONTRACTOR:
GRANTS LANDSCAPE SERVICE
PO BOX 221
SPRINGFIELD OR 97477
CeB # 10250 Expiration Date: 20/4 /9/30
DescriDtion
Amount Paid
Date Paid
Receint Number
Cashier
Back/low Device
Minimum/Adjustment Plum
+ 8% Administrative Fee
+ 7% State Surcharge
$14.00
$31.00
$3,60
$3,15
10/04/2002
10/04/2002
10/04/2002
10/04/2002
10755
10755
10755
10755
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 working day,
Reouired Insnections:
1 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, I further certifY that only contractors and employees who are in compliance with ORS
701.055 will be used on this project. I further agree to ensure that all required inspections are requested at the
proper time, that each address is readable from the street, and that the approved set of plans, if applicable, will
remain on the site at all times during construction.
Owner or Contractors Signature
Date