HomeMy WebLinkAboutPermit Plumbing 2003-5-14
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.: PLM2003-00025
ISSUED:
APPLIED:
EXPIRES:
5/14/2003
5/14/2003
11/14/2003
SITE ADDRESS:
ASSESSOR'S PARCEL NO.:
PROJECT DESCRIPTION:
5976 G ST
1702342200403
Backflow device
Springfield
TYPE OF WORK:
TYPE OF USE:
New
Residential
OWNER/APPLICANT:
MEYERS KENNETH & SHIRLEY
5976 G ST
SPRINGFIELD OR 97478
PLUMBING CONTRACTOR:
~
Descriotion
ttOl\CE: ~ \f lHE WORK
lH~S PERM\l SHALl1H,S PERM\l 'S NOT
AUTHOR'ZEO UNO~: A~~eONEO FOR EXPIRES
c:'&OMMENCE~ ~~f\\OO.
A~"t\i\9~A Date Paid Receiot Number
05/14/2003 1200200000000001192
05/14/2003 1200200000000001192
05/14/2003 12002Q~~OJ!mOOOOll92
05/14/2003 (\J~002'0.u~QSil0000 1192
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To R~quest a~ inspe~tion call the 24 hour recording ~t ~~d9~\~tm~~~~lj.s\'rJ~~~.!,@Q}e~o;~~~&t will be made the same
workmg day, mspectIOns requested after 7:00 a.m. wlllb~(r,\\\~\fj}e:Jst.m>'\vl'I\g\~\\n1fIng da~e \e 'i..\~\ca.\\
NO" ,....Q'Sl: "'J 0'0 l~\O\e. ;'b,JNO
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Reouired Insoections: \~090'~~9 \'(\0 ce~ o'{eQ,O~~~~'2.~'2.~
1 Backtlow Device: Prior to covering and provide a te~'t'_~\1:h'e'{t~(~~:)i~~n site at the time of inspection.
n\)~TJ'O Ce'{\
By Signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I 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. I further
certify that only contractors and employees who are in compliance with ORS 701.055 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, and that
the approved set of plans, if applicable, will remain on the site at all times during construction,
+ 10% Administrative Fee
+ 7% State Surcharge
Backflow Device
Minimum! Adiustment Plumbing
4.50
3.15
14.00
31.00
g~-~ ~~~
i' Owner orContractorg:;gIgnature
s-- (1-1 --O~
Date
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
City of Springfield
Development Services Department
Public Works Department
Official Receipt
Receipt #: 1200200000000001192
Date: 05/14/2003
Job/Journal Number
PLM2003-00025
PLM2003-00025
PLM2003-00025
PLM2003-00025
Item Total:
Amount Paid
14.00
31.00
4.50
3.15
$52.65
Description
Bac1d1ow Device
Minimum! Adjustment Plumbing
+ 10% Administrative Fee
+ 7% State Surcharge
Payments:
Type of Payment
Check
Paid By
KENNETH MEYERS
Received By
djb
Check Number Confirm No
How Received
In Person
Payment Total:
Amount Paid
52.65
$52.65
5/14/2003
2:45:53PM
Page I of 1
cReceipt.rpt
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22S mil-I STREET. SPRINGFIELD, OR 97477 . PH:(S41)726-37S3 . FAX: (S41)726-3689
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City Job Number P Lt/lIt 2..0(:):5. ~-o DO z~
lob Location S97("
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Tax Lot
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Assessors Map
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Addres~ ~?(/) F;.. $ 7'H)~ --f
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Zip 97t{'fl
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Stafp D I'-
BACKFLOW PERMIT IS $52.65 (includes Permit Fee, State Surcbarge & Administt'ative Fee)
Contractor Informat;on
Contractor
o L.../ tI CL
Addre~s
Phonp
City
Statp
'lip
Expires
By signing this pennit/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 infonnation on
this pennit/application is correct.
Signature~':':- ~/
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Dat~ ~- / l{- 0_1
For Office Use
Date of Application
0~~J
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Checked for Historical Status
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Checked for Delinquencipc;:
Shared Drive (T:)/Building Fonns/Baekflow Prevention I-D3,doe