HomeMy WebLinkAboutPermit Backflow Test 2001-6-27
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I Job# 01-00655-01 I
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Page 1 of2
TRANS#:01-00059B4
DA TE : JUN 27 2001
AMT RECD:2 $ 16.50
CHANGE:
CASHIER: 061
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CITY OF SPRINGFIELD, OREGON
RESIDENTIAL PERMIT
City Of Springfield
Community Services Division
Building Safety
225 North Fifth Street
Springfield. OR 97477
Location Of Proposed Site: 841 Old Orchard Ln Spr
Assessors Map#: 17032343
Lot: Block: Addition: 3rd
Owner:
Address:
Future B Inc
Po Box 7425
Scope Of Work: Backftow Device
Backftow device
Job Number: 01-00655-01
Office: 726-3759
Inspection Line: 726-3769
Tax Lot #: 02102
Subdivision: River Glen
Phone Number: 541-744-2660
City/State/Zip: Eugene. OR 97401-0017
New
Value:
RESIDENTIAL PERMIT
City Of Springfield
Community Services Division
Building Safety
225 North Fifth Street
Springfield. OR 97477
Job Number: 01-00655-01
NonCE: . O~ce: 726-3759
THIS p~nspectlon Lme: 726-3769
A RMIT SHALL EXPIRE IF
Old Orchard Ln Spr UTHORIZED UNDER THIS THE WORK
COMMEr.fx:CO,M:iS AlfAR6~ERMIT IS NOT
Addition: 3rd ANY 1 BOSubdlvision' River GI~fiD FOR
. -, I/Dr'
Location Of Proposed Site: 841
A,;sessors Map#: 17032343
Lut: Block:
Owner:
Address:
Marlyn Thompson
841 Old Orchard Ln
Scope Of Work: Backftow Device
Backftow device
Contractor Type
Plumbing Contr
Contractor
Hunter Irrigation and Landscape
25226 Strawberry Lane. Veneta. OR
97487
Quad Area:
II Of Units:
Constr. Type:
Water Heater:
Office Use
Land Use:
Zoning Code:
Bedrooms:
Range:
1
(VN) Wood Frame
Phone Number:
City/StatelZip: Springfield. OR 97478
New Value: $0
...., 'ENT/nll,.
Registration !#ule~xpir'ati9nll;>J1.tere . Phone
.Notification C adOPted by the JUtres You to
to OAR 952'00etter. Those rUle;egon Utility
0090. You ma -0010 through 0 are Set forth
Ca/Unh". Y Obtain "nh', AR 95:>.on.
nUmbe;i~';t;,:~er. (Note: t;;ev;:~e rUles by
C reann II.", ephone
ente '# O"B 'Id" .... 'I '.
" "',~ UI mgs. ot,f,cat,'
. V"'V-lj~::>a""'~" , On .
Occupancy'GroUp: Dwelling
Heat Source:
Sq. Footage:
.
1
(VN) Wood Frame
I Job# 01-00655-01
Office Use
Land Use:
Zoning Code:
Bedrooms:
Range:
.
Page 2 of2
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Quad Area:
# Of Units:
Constr. Type:
Water Heater:
# Of Buildings:
Occupancy Group: Dwelling
Heat Source:
Sq. Footage:
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.
Bacltflow Device
Required Inspections
I Plumbing I
-After device is installed but before backfilling trench,
Construction Types:(VN) Wood Frame
Occupancy Groups: Dwelling
# 01' Buildings:
# 01' Bedrooms:
Handicap Access? 0
,Area (Sq. Feet)
I Main: Accessory:
# Of Stories:
Current Units:
Census Code: Does not apply
Private Garage/Carp/Stor
Height (feet):
Proposed Units:1
Total:
Fee
Paid On Receipt#
I Plumbing
06/27/2001 5984
06/27/2001 5984
06/27/2001 5984
06/27/2001 5984
Value/Quantity
Fee Amount
Minimum Plumbing Permit Fee
State Surcharge - Plumbing
Backftow Prevention Device
Administrative Fee - Plumbing
Total Plumbing
Grand Total
1
$5,00
$1,05
$10,00
$.45
$16.50
$16.50
By signing this permiUapplication. I agree to call for an inspection once the backflow prevention
device has been installed and is visible for inspection (726-3769). 1 also state that all information on
thispe Z~ct.
I#ture
,
,j" - ;)..';1-tJ> /
Date
.
.
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: ?~/ t9Lt:J tJ/?C/;I#-/f'LJ
ASSESSORS MAP #: 1703'7-'343
TAX LOT #: DZ(Oz..
OYNER: m.4,{J lvM T)"/,,~J"".v
ADDRESS: ;:-,//"':>0\ D&rfj)a{\
CITY: oJ 41',:,,,; (]~ 1'<<") STATE:
PHONE #:
C!?/.
ZIP: , C;I',y? '7
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CON1'RACTOR: Jr/.....^/I....f' r."f"f1,~~:.., ~ .IA_,/1,ScAA. ~,,..
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ADDRESS: Ls-J.2f .s77f'~L,.('~/ 1-.-- PHONE #: 9.rf-3.2./..r-
CITY: J.,/.c.",.......'"'T79-
STATE: tSJ~
ZIP: ;7tl~?
CONSTRUCTION CONTRACTORS REGISTRATION #: //7' '? ?
EXPIRES: ~ -.?.a..a. Z
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BAOCFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. '
p.~
DATE
;;-.:2 7-c:l'/
FOR OFFICE USE
DATE OF APPLICATION: 0 b '2 7 0 /
<;,9551
JOB #: 0/-0 ObSS-D(
TOTAL AMOUNT COLLECTED:
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ISSUED BY:
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RECEIPT #:
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