HomeMy WebLinkAboutPermit Plumbing 2003-4-8
II
I
,.
.
..
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
PERMIT NO.:
ISSUED:
APPLIED:
EXPIRES:
PLM2003-00019
4/8/2003
4/8/2003
10/8/2003
SITE ADDRESS:
ASSESSOR'S PARCEL NO.:
PROJECT DESCRIPTION:
2193 FIRTH AVE
1703251206200
Backflow device
Springfield
TYPE OF WORK:
TYPE OF USE:
New
Residential
OWNER! APPLICANT:
SMITH TERESA L
2193 FIRTH ST
SPRINGFIELD OR 97477
f: IP~UiMBINL.~:CTOR:
"01\C . \1 Sr\~ \l9"4'w~',,-O\'.
ir\\S ?t.\'.W\ \l~ OO~t.O f OR 97405
r>-\\ir\O?-\lt.~O o\lf\!D . 41-431-6616
GWlWlt.~C ?t.?-\OO.
c.r>-~'1 '\ 8\) '0r>-'1 CCB# 7433 EXPIRES 05/31/2002
Descriotion Amount Paid Date Paid Receint Number
+ 10% Administrative Fee 4.50 04/08/2003 2200200000000000712
+ 7% State Surcharge 3.15 04/08/2003 2200200000000000712
Backflow Device 14.00 04/08/2003 2200200000000000712
Minimum! Adiustment Plumbing 31.00 04/08/2003 2200200000000000712
,/outo
_ ......ltJ regU\fQS . 'l\\\t\I
QN'.Ule~u... ttlsOI&Yu" - ~ttt
To Request an inspection callthe 24 hour recording at 72(jl,;rj'@~lhl.~\lbilr;\~~u{,slllllYllfOf~71ga~\ will be made the same
working day, inspections requested after 7:00 a.m. will b"l6\IIll\Nt~~W;'e~iJl8\W61~"'d~...... Ol'f\ 9 ""$ try
.;'J:~_at\O" _".....nthfbu'i'. 1\""0. fU\a
l'Iv....- 2-Qu ,-v- pIe:; U' -. n8
Reouired InsDections: in Op..f\ 95 roa'/ obtain:,O \8: tn8te\9~~O tiOn
nQO. 'fcu ~I. ~t.o Not\1lca
1 Backnow Device: Prior to covering and provi~1l-e~ftIll6tJre:tOOq IlfQ6l\~\\llItlie4ti?1e oCinspection.
C 101 ttl9 1 n_'\32-i34 fl
By Signature, I state and agree, that I have careCully examinllll!til~~lW?/..!\tI4 ilp~llcalion and do hereby certiCy that aU
inCormation hereon is true and correct, and I Curther certiCy that anyl/nd all work perCormed shan be done in accordance with
the Ordinances oC the City oC Springfield and the laws oC the State oC Oregon pertaining to the work described herein. I Curther
certiCy that only contractors and employees who are in compliance with ORS 701.055 will be used on this project. I Curther agree
to ensure that an required inspections are requested at the proper time, that each address is readable Crom the street, and that
the approved set oC plans, ifapplicable, will remain on the site at an times during construction.
fy~~
Owner or Contractors Signature
V -8 -0 3
Date
'!,!l"j ~~lfJ.~~. .'"F"~'7' .-".:...
Wi!' ·
.
-......... '
., ~J' .,. I
'. r: "'-~._l
..~..,., ...c_, ....-,..,i"'C:;, ...-" "...~M
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Line I terns:
Job/Journal Number
PLM2003-000 19
PLM2003-000 19
PLM2003.000 I 9
PLM2003-000 19
Payments:
Type of Payment
creditcard
Paid By
Description
Backflow Device
Receipt #: 2200200000000000712
Date: 04/08/2003
Minimum/Adjustment Plumbing
+ 10% Administrative Fee
+ 7% State Surcharge
DAVID A GAMACHE
Received By
Check Number Confirm No
djb
000038
049787
Page I ofl
-,
4/8/20~3
1:45:4IPj\1
;
City of Springfield
Development Services Department
Public Works Department
Official Receipt
.
Amount Paid
14.00
31.00
4.50
3.15
Line Item Total:
$52.65
How Received
Amount Paid
In Person
52.65
$52.65
.
Pavment Total:
cReceipt.rpt
'l
ZZO fIITH STREET. SPRINGFIELD, OR 97477 . I'H:(041)72(;-:,703 . FAX: (041)72(;-3(;89
Q:
C))
...:/,...;.(~
~~
~~
Q) Assessors Ma:,
.,~~~
~1
~,
~~l;
~:
City 5F!,<,z".)&f-:C-€-c. D
~)
"~.'~Il
! - j
-- j
~
~\ Contractor Information
Gll))
~)
-J- ,~__=I~
~
~
If".'
~l
~j
Hi
~
..a~~
~.--:~
Hi
~
~
~
~i
f'~lj
~
~
OJ
r'T--=lj Date of Application
,.,
~:
~) Checked for Delinquen(': p<
~
~l
;... --.
.
. L.c B free. fr . ::)0;' 3 7~ "-(sel
. 37S~ V6?1
CITY OF SPRINGFIELD, OREGON
. ()U'l1 z,003 ,000 I 'i
City Job Numb., r I
Job Locatior.) I q '3 cfJ::-I?.(7-f Au~.
/703,ZSt z..
Tax Lot
062-00
Owner 11:r<. i_ S Ii c:; /'-1.:L T rt
Addrp~< ;;1./1 ~ p,J;((...f)-( A- u I{..
Phon/'
Statp
DfZ
Zip q 7':i 1 7
BACKFLOW PERMIT IS $52.65 (includes Permit Fee, State Surcharge & Administrative Fee)
~\.o
Contractor ;\Jf..w /VI 0010 MA-;e. D ..(0~ ~'$(.
. eu,,- ~~ 'Ifb".$F.....
Addrers ip.O, B:?x S-C/'1 Y ;J'~,''b~~e~~'''~~~~~~np{<5V'') tJ31-66! h
O~'t) 6'01 e~' 0"'" e\~~1iJ '-
.s:::: .t< ~. ~\.0 0'0 ~ A~.;\\"'-. o~ a 7 -
Cit.. v UG ~ tV IL. \,:-,0 ~GO .' ~~ ~S'~~V'''~ {~~f.:.# Zip t' V () ...s.
. ~~ ...s.e'r> ve<'i-~\IJ. cO ~";\o~,. J .
Construction Contractors Regiam\~~~~ ~o;- $~~"'3 Expires,~ 1-;; ( /0 :3
. ::~~ ,'" t,.J "",vi~;r:~u _"'...."
"'- 0"'" --lOu eV"' O'-...~\l'-
\~ ~. ^Oi'S" ~8 '\'''
~~(?J '&.~.... \0\ e\ \'"
By signing this permit/application, 1cf~~~~'i for an inspection once the backflow prevention
devise has been installed and is visib1'e for inspection (726-3769). I also state that all information on
this permit/application is correct.
C) ~~~.
SignatureV-~ /~ ,~\'i~~~~~8-03
't.'j..\'" '?'t.~~' 'i\)~
. ~~\,\, ,\'(-.\S r:J~'t.'V
...~\'~. ,0''\ <;) ,\<;\'t.~ ,~~~'V
#J't.;;flk~\" \)\,. ~ fo-
..y.wu,!;h.\~<:l 'V~ ~,(\'V.
. ~\)'\'<'~'t.~""t.~ ,?'\:..\,l
o l{ ~O 8' -0 '3:> c.'V~ \'0<;) 'V
t~'
V
/
Checked for Historical Status
Shared Drive {T:)/Building FomlslBackflow Prcventionl-03.doc
Q.,
'"
~
~
00
o
o
~
'"
<0
o
:z
"-
r--
~
'"
0-
'"
"-
00
~
'"
'"
o
o
'"
00
=
Q.,
<C
~
~
=
0-
"'---.~_""
I -
Cl
::E
Co
=
~
tt~;~:;,?:.- ., ;":-,' _: '-'
, '.... 'r". . "... " ,'-
);~fi!!:~f\>"::;i':~; i~;::'\
.' .'~~
,':..
11___.._"._..__
,.._.'t
I.~JI~
'.~.
~
~~
c :: ~
~ ,?- ~
r J~
1fL
.-1~
+:
C?~ ~
~
, "
0''' ~
~t
ct
~ ~
V
J~Q!..
01
-
[ So
~a-'r
~>
. -(
\'
.
y;
...
~
...
IR
...
Cl\
.
D
~
~
~
w
~
,
"lJ
I\J
/,