HomeMy WebLinkAboutPermit Plumbing 2011-6-2
Plu"!bing Permit Application
'1""crrv OF S~RI~GliIELD,'pRE~dN<:.'~
. ,^," , j'.. ./. ,-'
225 Fifth Street. Springticld, OR 97477. PHt54 1)726-3753 . FAX(54J)726-3689
OEPARTMENT USE ONLY
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Date:
<:;-;)- II
This permit is issued under OAR 918-780-0060, Permits are issued only to the person or contractor doing the work. Permits
expire if work is not started within 180 days of issuance or if work is suspended for 180 days.
lOCAL GOVERNMENT APPROVAL
Zoning approval verified? 0 Yes 0 No
Sanitation approval verified? 0 Yes 0 No
CATEGORY OF CONSTRUCTION
o Residential 0 Government 0 Commercial
JOB SITE INFORMATION AND lOCATION
Job site address: I~D i
City:
ZIP:QNO[)
City:
Phone:
E-mail:
This installation is being made on residential or fann property
owned by me or a member of my immediate family, and is
exempt from licensing requirements under OAR 918-695-0020.
Signature:
CONTRACTOR INSTAllATION
Business name: tJ.M
Address: ?a~ 85({p
City:
Phone:
State: 19R..
ZIP: ql<f<:JE:>
2.4-3D
Signature: . _, ,i.M' "n,'
ATTENTION: d rJ(~:by';h';o~~gon Utility ~
follow rules a op e e rules are set forth
Notification Center, ThhOS hOAR 952.001' ^~,
, OAR952001.0010t roug b ?)v\V tv-
In . btain copies of the rules y ~,o
0090" You may 0 Note: the telephone
calling the chen~r~g(on Utility Notification ....~ ~
number for t e r 2344) W.. U
Center is 1-800.332.. ~
440.2500.J (11/08/COM)
FEE SCHEDULE
Description Qty. Cost Total
ea. cost
New residential
I bathroom!1 kitchen (includes: first
100 feer oj water/sewer lines. hose $238.00 $
bibs, ice maker, under floor low-point
drains and rQin~drain packages)
2 bathrooms/ I kitchen $374,00 $
3 bathrooms/l kitchen $439.00 $
Each additional bathroom (over 3) $95,00 $
Each additional kitchen (over I) $95.00 $
Residential fire sprinklers (includes plan review)
o to 2,000 square feet $58,Q0 $
2,00 I to 3,600 square feel $116,00 $
3,60 I Lo 7,200 square feeL $174,00 $
7,20 I square feet and greater $232,00 $
Manufactured dwelling or pre-fab (circle one)
Connections to building sewer and $58,00 $
water supply
Commercial, industrial, and dwellings other than onc- or
two-family
Minimum fee $58,00 I $
Each fixture $19.00 $
Miscellaneous fees
100' storm, sewer. water line $76.00 $
Each fixture, appurtenance, and piping $19.00 $
Storm water retention/detention facility $19,00 $
Irrigation systems I $19.00 $
Piping or private storm drainage $19,00 $
systems excecdinQ. the first 100 feet
Specialty fixtures $19,00 $
Reinspcction (no. of hrs. x fee per hr.) $58.00 $
Special requested inspections (no. of $58.00 $
hrs. x fee per hr.)
Each additional inspection: (I) 558,Q0 $
Medical gas piping Minimum f...:c $
Enter value of installation and equipment $
Enter fee based on installation and equipmellt value. $
, APPLICANT USE,
(A) Enle~1aI",~.lnlVe fee? $ Scf-
(Minimunyre;.mit Fee $58.Qu) "
(B) Investigallve lee (equal 10 [AJ) $ C /p
,(<,:j'!;:rttr.12% surcharge (.12 x [A+BJ) ,,,"n~ $ Z- '7"'
'.i!?).t~'i.1l'J9.!\1!\)'!ie~i(5.%Qf:(Rjj'\t Ir ': '~,n' "~T $ / ~
,"~Q;(A~ l~e~nt~~,siJEch:i'l-~J~(i\liii\l~i)J: $ V:J I,
"'U' "v." BA\\IUU\~t:1 I u"
COMMENCED OR IS A
ANY 180 DAY PERIOD,
7SP:~"N"" G.": IEl~
~""'"~,
C'. ('!:Iii
" :..~ OREGON
www.ci.springfieJd.or.us
TRANSACTION RECEIPT
811-SPR2011-01266
1480 16TH ST. APT 1
CITY OF SPRINGFIELD
225 Fifth 81
Springfield,OR 97477
541-726~3753
permilcenter@ci.springfield.or.us
. F+" >~ AC.C.o.UNT~C:ODE :;""'''''';;' ..-AMQUNI~D.UE
224-00000-425603 19.00
224-00000-425603 39.00
821-00000-215004 6.96
100-00000-425605 2.90
TOTAL DUE: 67.86
l_PAYMEN'crY~E ____oPAyOR_ .cASHIER: NMA.~H~ci, :.._:.: ~ ~C.C>MMEN1:S ..:~'___:l.:":" -----=-- __~I\'IOUNT PAID
Credit Card TRAVIS LAMB 67.86
03811C
RECEIPT NO: 2011001414
lDESCRll?l"10N- '-,
Backflow preventer
Balance of Minimum Plumbing Permit Fees
State of Ore90n Surcharge (12% of applicable fees)
_ _.:r~chn-"logJ fee (5% of permit total)
RECORD NO: 811-SPR2011-01266
DATE: 06/02/2011
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TOTAL PAID:
67.86