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HomeMy WebLinkAboutPermit Backflow Test 2002-8-7 '. ~. Page 1 of 2 : TRANS#:01-0010206 DATE:AUG 07 2002 AMT RECD:2 $ 51.75 CHANGE: CASHIER:061 I Job# 02-00948-01 I . 225 Fifth Street Springfield, OR 97477 CITY OF SPRINGFIELD, OREGON RESIDENTIAL PERMIT City Of Springfield Community Services Division Building Safety Job Number: 02-00948-01 Office: 726-3759 Inspection Line: 726-3769 Location Of Proposed Site: 4969 Forsythia St Spr Assessors Map#: 18020422 Lot: Block: Addition: Owner: Tax Lot#: 03100 Subdivision: Connie Secrist Phone Number: 541-747-2678 City/State/Zip: Springfield, OR 97478 New Value: $0 Address: 4969 Forsythia Street Scope Of Work: Backflow Device Contractor Type Landscape Quad Area: # Of Units: Constr. Type: Water Heater: Install backflow device C t t R. . # E. -.... r<'(IUlleD's yoU \.u on rac or eglstratlon~(lol xplratlon ateJtillty Phone "YT.E\'l I IU"'~' d ...,,'heUHl\,jV" t ~n Grants Landscape Service " 10250,sadopte 9/30/20023 are set '541-746-8482 Po Box 221, Springfield, OR 97 477 to\.\tO;a~i~~ Centel. ihOhsOe ~9uhv OAR 952-00b~- "'nt" _..... nn10t r ... _ ...,\ee:=. V Office USE'-' (lARy"''';;;;;y obtain COPI~~~\~i~phO~e Land Use: OO~~ili;9 the cente:~ t'tr~pj\~!!jlllif1~i;.atlon Zoning Code: numberlOl tM? 1_i&,c;s!!pa-ric~,1Group: Bedrooms: Center IS Heat Source: Range: 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. Construction Types: Occupancy Groups: # Of Buildings: # Of Bedrooms: Handicap Access? D ,Area (Sq. Feet) I Main: Accessory: Backflow Device Fee Required Inspections I PluliiDUfd;t: I -After device is installed but QE1IO'fJlftiaali.fillfngltlllbl:hEXPIRE IF THE WORK AUTHORIZED UNDER THIS PERMIT IS NOT COMMENCED OR IS ABANDONED FOR ANY 180 DAY PERIOD. # Of Stories: Current Units: Census Code: Does not apply Height (feet): Proposed Units: Total: Paid On Receipt# ~ Plumbin!! 08/07/2002 10206 Value/Quantity Fee Amount Minimum Plumbing Permit Fee $31.00 .~ . - / Job# 02-00948-01 . Page 2 of 2 Value/Quantity Fee Amount Fee Paid On Receipt# Plumbin!! 08/07/2002 10206 08/07/2002 10206 08/07/2002 10206 1 $3.15 $14.00 $3.60 $51.75 $51.75 State Surcharge - Plumbing Backflow Prevention Device 8% Administrative Fee - Plumbing Total Plumbing Grand Total By signing this permit/application, I agree to call for an inspection once the backflow prevention device has been inst led and is visible for inspection (726-3769). I also state that all information on this per~t aif,pr at" n:rue and correct. ~ J/ ___ f-7-oL Signatu~ Date 225 F1ITH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 5 .. 'r-c14 l~ ~ Assessors M~r ..~ ~ p,.,. Owner Lb/u/Il/e-- S(J'Cf-(S",- ~ Add=, 41(,1 !ifj477!"+- ~ City sefL-tJ . 'I ~ Contractor Information ~. ~ ..~ > ~ Q ~ ..~ ~ & ~ ~ ~ ~ o ~ 1 M .-" . . / CITY OF SPRINGFIELD, OREGON TRANS#:01-0010206 DATE:AUG 07 2002 AMT RECD:2 $ 51.75 CHANGE: CASHIER:061 City Job Numb.. OZ -00 9Lf r -01 Job LocatioI' tf1!Ptf f6f.5r11lfr1f- Sflf/Uj). ()f!- 77tJl!' I ~O 2..(Y-fZ- 'Z..- , , Tax Lot 03/00 Phnrp 7C(7-Z& 7f Statp D;L- Zir 97Y7Y BACKFLOW PERMIT IS $51.75 (includes Permit Fee, State Surcharge & Administrative Fee) Contractor GjUl1VI~ Wt>S<APe- ~\C8"S Address p, 0, ~Ox.. ZZ I Phonp 7),C,-J'OJ.Y Statp 6(L 7ip '17Y7! Cit:' 5rFGIJ. of.- Construction Contractors Registration # /02 s-O 0'93002.... Expires By signing this permit/application, I agree to call for an inspection once the backflow prevention devise has been installed and is visible for inspection (726-3769). I also state that all information on this permit/apPliczatiozn's. c:Jle . 0-]-0 z.., Signaturp Datp 0 For Office Use Date of Application 08070L.. c..---- Checked for Historical Stan'. ...--- Checked for Delinquencip< Shared Drive rr:)/Building FormslBackflow Preventionl.o2.doc