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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". . "... 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