HomeMy WebLinkAboutPermit Plumbing 2001-7-24
I Job# 01-00779-01, I
Page 1 of 2
TRANS#:01-0006234
DATE:JUL 24 2001
AMT RECD:1 $ 16.50
CHANGE:
CASHIER:061
CITY OF SPRINGFIELD, OREGON
INDUSTRIAL PERMIT
City Of Springfield
Community Services Division
'Building Safety
Job Number: 01-00779-01
225 North Fifth Street
Springfield, OR 97477
Office: 726-3759
Inspection Line: 726-3769
Location Of Proposed Site: 1701 S a St Spr
Assessors Map#: 17033600
Lot: Block: Addition:
Tax Lot #: 600
Subdivision:
Owner:
Address:
Springfield Utility Board
1001 Main Street
Phone Number: 541-744-3726
City/State/Zip:Springield, OR 97477
New Value: $0
Scope Of Work: Backflow Device
Backflow device
Contractor Type
Plumbing Contr
Contractor
. Unknown
x,x,X
Registration # Expiration Date
Phone
Office Use
Quad Area: Land Use: # Of Buildings:
# Of Units: Zoning Code: Occupancy Group:
Constr. Type: Bedrooms: A ~~a~ Sour~e: .
Water Heater: Range: f ,IT, ENTIOS~9Foo1age"V reqUIres you to
o ow rIJIA~ ~d('\!"tarl h.. +!_~ 0-- - - - I ......
_ . '. I -- -J ....- -IV~UI~ VLlIUY
. . . . . NotlflGatlon Center J.:hn~a r"l- f
To req~est an inspectIon call the .24 hour ~ecordl~g at 726-3769. AIII~rl~e~W>gg2.~gue_~re'~ I).efore ~;0E) are set orth
a.m. wIll be made the same workIng day, InspectIons requested after Oed<f.'~' willli)~ m~a~ tREPf~10"in@ 952-001-
working day. ::I '. ou may obtam copIes of the rules by
callmg the center. (Note: the telephone
Required Inspections ~:L:-:-:::;- ~':'. 11.0 C, "'!:lUll UlIllIY (\JotJtlcation
I Plumbing I Center is 1-800-332-2344).
Backflow Device -After device is installed but before backfilling trench.
Construction Types:
Occupancy Groups:
# Of Buildings:
# Of Bedrooms:
Handicap Access? D
-Area (Sq. Feet)
Main: Accessory:
r,IOTiCE:
THIS.PEIiMIT SHALL EXPIRE IF THE WORK
# Of Stories: Alt1'~~Wifl~u~;N
Current Units: CcrM~p.osed lYmR.~R THIS PERMIT IS NOT
Census Code: Does not apply Ic:NCED OR IS ABANDONED FOR
ANY 180 DAY PERIOD.
Total:
Fee
Paid On Receipt#
Plumbing
07/24/2001 6234
Value/Quantity
Fee Amount
Minimum Plumbing Permit Fee
$5.00
w",
Job# 01-00779-01
Page 2 of 2
.Fee
Paid On Receipt#
, Plumbinij .
. 07/24/2001 6234
07/24/2001 6234
07/24/2001 6234
Value/Quantity
Fee Amount
State Surcharge - Plumbing
Backflow Prevention Device
Administrative Fee - Plumbing
Total Plumbing
Grand Total
By signing this permit/application; I agree to call for an in~pection once the backflow prevention
de~e has been installed and is visible for inspection (726-3769). I also state that all information on
this p_ermit applicati9n is true and correct.
fY1fJ1JLuY1u-orU . 7- 2>+.0/
Stgnature Date
1
$1.05
$10.00
$.45
$16.50
$16.50
BACKFLOV 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:
I r;o/ S..A Ji-.
ASSESSORS MAP #:
J7033 ~OO
TAX LOT it: ~ 6 b06
OWER: U. u. i?J '
ADDRESS: 100 I m Pt / Af ST.
CITY: 0Dn'n4.h"e1d
V V
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50
PHONE it: '7 2-Lf;--- 2-3 9s
STATE: DR- ZIP: 9'7<..jY}1)
CONTRACTOR: (J.n /UlD10ll [l.;:t; -du':s -b rYLeJ _____
ADDRESS: ~. #:' '
CITY: ~
. /" '-........
CONSTRUCTION CONTRACTORS REGISTRAT~N it: ~
ZIP:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR I~SPECTION .
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS
CORRECT.
&~iJ~fc;x)
SIGNATURE
') -c;;l Lf~{) I
DATE
FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
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DATE OF APPLICATION:
RECEIPT #:
ISSUED BY:
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