HomeMy WebLinkAboutPermit Backflow Test 2004-4-19
. Lll r OF SPRINul'lJ<..LD
Building/Combination Permit
PERMIT NO: COM2004-00439
ISSUED: 04/19/2004
APPLIED: 04/19/2004
EXPIRES: 10/19/2004
VALUE:
.
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 1805 PIONEER PARKWAY EAS Springfield TYPE OF WORK: Backfiow Device
ASSESSOR'S PARCEL NO.: 1703262302001
TYPE OF USE:
PROJECT DESCRIPTION: RP device
Owner: JACK IN THE BOX INC
Address: 1777 NE LOOP 410 STE 1015 SAN ANTONIO TX 78217
I CONTRACTOR INFORMATION I
Contractor Type
Plumbing
Contractor
BARRlCH INC
License
106824
BUILDING INFORMATION 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 TY_~~t\~'4-
Enerw-tl\Jlt:' ~\
_'P\9>~ ~....J\\\ \~ ~
t'~. ~\\~~'Ii~9rOO\~FORMATION I
SETBACKS ~\)"\\~'t.~~~ \'}~\)\.~ ~~\'I.I"
Front yard Setback: \\\\~ \\~~\t'?; ~~ ~~ '\ :-.~~.Overlay Dist:
Side 1 Setback: ~\'}\ ~'t.~\' ~ ~'t.~ # Street Trees Rqd:
Side 2 Setback: C~~ \'O~ ~t>' Paved Drive Rqd:
Rearyard Setback: \>-~'{ , % of Lot Coverage:
Solar Setbacks: oU \0
,...o~~ .,.."....
VN
Street Improvements:
Storm Sewer Available:
Special Instruction:
.. . - .. t~..
. IPWJ,bl€'II\m~QVEM..E~S I
~.Ole.v d 'e'! ,... \as'" - 5'2.-Vv
~~\\O 'do~\8 ~osa tU Of>.~ 9 u\eS \
f>." ~ lU\asca.a{\\al. \0 \~IOU~~ 0\ \~'e I ~ol'la
\0\\0 . n 00" "laS a\a~ . 1'I
"'Ca.\IO "0'" 'nco" .\~a\ "'ca.\\o
-1.0\1'1 95'1.'" 0'O\a.\ ~o\a. ~O\\,\
Of>.~ U ~a.'! \al. ~ u\i\i\'! AA\.
\~()90. :~.. \~a ca~ ()la~~~.'l"?'??o
ca.'''' -t\ot". ....
l'Iu'lfI'Oa .1 Valuation Descriotion I
New
Commercial
Expiration Date
06/0712007
Phone
503-652-2626
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Impervious Surface Area:
REQUIRED PARKING
Total:
Handicapped:
Compact:
Sidewalk Type:
Downspouts/Dralns:
Notes:
Deseription
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Tvpe of Construction
Total Value of Project
Page 1 of2
Value
Date Calculated
.
. CITY OF ~r KlNGFIELD .
Building/Combination Permit
PERMIT NO: COM2004-00439
ISSUED: 04/19/2004
APPLIED: 04/19/2004
EXPIRES: 10/19/2004
VALUE:
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
F~~s ~
Fee Description
+ 10% Administrative Fee
+ 7% State Surcharge
Backnow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
Receipt Number
$4.50
$3.15
$14.00
$31.00
4/19/04
4/19/04
4/19/04
4/19/04
1200400000000000500
1200400000000000500
1200400000000000500
1200400000000000500
Total Amount Paid
$52.65
I Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769. All inspection requested bcfore 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.
I R~ouir~d Tnsn~dions I
1 Backfiow 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 1 have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and 1 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 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, 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.
otL~~..Y~
--1' -- /9 -c)~
Date
Page 2 of2
.
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2004-00439
COM2004-00439
COM2004-00439
COM2004-00439
Payments:
Type of Payment
CreditCard
4/1912004
RECEIPT #:
.,P.R~'f~"~ ....;
U&.. . i
~'l
ar of Springfield Official Receipt
.elopment Services Department
Public Works Department
1200400000000000500
Date: 04/1912004
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Backfiow Device
Minimum! Adjustment Plumbing
Paid By
MRP SERVICES
Item Total:
Check Number Authorization
Received By Batcb Number Number Huw Received
djb 000359 022876 In Person
Payment Total:
Page I of I
1:37:36PM
Amount Due
3.15
4.50
14.00
31.00
$52.65
Amount Paid
$52.65
$52.65