HomeMy WebLinkAboutPermit Backflow Test 2004-8-26
.
. CITY-OF SPRINGFIELD'
Building/Combination Permit
PERMIT NO: COM2004-01066
ISSUED: 08/26/2004
APPLIED: 08/26/2004
EXPIRES: 02/26/2005
VALUE:
,
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 1930 SCOTI RD
ASSESSOR'S PARCEL NO.: 1703254300100
Springfield TYPE OF WORK: BackOow Device
TYPE OF USE:
New
Residential
PROJECT DESCRIPTION: BackOow device
Owner:
Address:
MCDADE REATHA A ,"iG9~.x;,
1930 SCOTT RD SPRINGFIEL& ~ ~~ U\\~o~
,..I'\feg ..,'\<\9 .~ "Iil\ \
~\Vi" :teu- ~\Sl>-' o.~'2.NU
~~()'l3IU\sS a6:t. Ilro~:.cBa'QifuR,Il\l"lIDRMATlON I
~~ 01\~ ""'11...'r .~SO{' "'Of\!J
. 1)'1 -\IV cO?\'" ~e?\'
, . :""<>'l O'o~f\ t\\ :te: \\,6 \6 ~~\ce.\\O(\ License
~_ ~1!.l\~~~!~~fI.~~~O.~ 10250
~\f\9J "~ot ~ f)'hJiilDINGl:NFORMA TlON I,
~~e'l f\~....,
~ # or Stories:
R-3 Height of Structure
Type of Heat:
Water Type:
Range Type:
Energy Path:
Sprinkled Building:
Expiration Date
10/31/2004
Phone
541-342-1835
Contractor Type
Landscape
# or Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
VN
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft GaragelCarport
Sq Ft Other:
Occupant Load:
nla
I DEVELOPMENT INFORMATION I
Frontyard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
REQUIRED PARKING
Total:
Handicapped:
Compact:
Street Improvements:
Storm Sewer Available:
Special Instruction:
_ ...1.1~ ~Cl~~
I rUDLIC IMPRpVEMENT~ l 't.'I-'r\'r.'c. ~?~\\ \~ \'lV'
~O \ \~~'r.~\\~\~\)'t.'r. \~&~tC.~~~~
\f\~~f\Cl'r.\l't.Cl ~ Cl'r. \~ (>.~ownspouts/Drains:
r>; ~~'t.~C,t: ~ 'r't.'r.\Cl'i."l.
CCl \ ~\) Clt>:
(>.~'l
Notes:
I Valuation Descrintion I
Description
Type of Construction
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Value
Date Calculated
Total Value of Project
Pa2elof2
.
. CITY OF ~rtul.,GFIELD
Building/Combination Permit
PERMIT NO: COM2004-01066
ISSUED: 08/26/2004
APPLIED: 08/26/2004
EXPIRES: 02/26/2005
VALUE:
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
L.Fp.p.~ PaW
Fee Description
+ 10% Administrative Fee
+ 7% State Surcharge
BackfIow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
$4.50
$3.15
$14.00
$31.00
8/26/04
8/26/04
8/26/04
8/26/04
Receipt Number
1200400000000001267
1200400000000001267
1200400000000001267
1200400000000001267
Total Amount Paid
$52.65
I Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769. All inspection 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 work
day.
I Rp.o,uirp.d ~
BackfIow Device: Prior to covering and provide a copy of the test report on site at the time of inspection.
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, and
that NO OCCUPANCY will he made oIany structure without permission of the Community Services Division, Building Safety.
I further certify that only contractors and employees who are in compliance with ORS 701.005 will he 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, that the permit card is located at the front ofihe property, and the approved set of plans wllI remain on the site at all
times during construction.
'- ~ ~ S-bta(tJ(/
Owner or Contractors Signature Date
Pal!e 2 of2
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2004-0 1 066
COM2004-0 1 066
COM2004-0 1 066
COM2004-0 1 066
Payments:
Type or Payment
CreditCard
8/26/2004
.
RECEIPT #:
.'''''~~'--'.!
u...~. _ :
~..' I';
aY of Springfield Official Receipt
.velopment Services Department
Public Works Department
1200400000000001267
Date: 08/26/2004
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Backflow Device
Minimum! Adjustment Plumbing
Paid By
JERRY DELAPLAIN
Item Total:
Cbeck Number Authorization
Received By Batch Number Number How Received
djb 016291 In Person
Payment Total:
Page 1 of 1
11:20:18AM
Amount Due
3,15
4,50
14.00
31.00
$52.65
Amount Paid
$52,65
$52.65
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05/25/04 TUE 08;41 fAX 54172U3689
ZZ5 f1fTIl STREIT . SPR!.l\IGI1EI.D, OR 97477 . PH;(f,41)7l(6-S75S . FAX: (54IJ726-36S9
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.BACKFL~~~~~t~(\'i?ee, Stale Surcharge & Administrative Fee)
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City Job Numbed DM'Zc:04 - 01 Ob b
Job Location /930 .3t a-I- qoo.d
Assessors M,l' /703, Z <) '-{ '3
Tax Lot
Owner
1711,s ..
Phon.
Zie'
City /;./9" ,LD
,Stal~ Dr
Zip
Construction Contractors Registration #
"7-J J/r,
00/00
97C/77
Expires-I!
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By signing this permit/application, I agree to call for an iru;pccti~~~~~l~'t prevention
devise has been installed and is visible for inspection (726-~~~\~~~'lful1 all infonnation on
this pem1i.t/apphcation is correct. \fU~' -lI.\\ S ;'V~ ~<Q~
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Signa~ .::s~.1'!:' F //~~t.y,.~~~~'?~ Dat~ Y/,;?r,Io<l
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SfJ.nd Drtvc (T;)'Buf1dUl; FoonslBtckl1aw Pl'e\le:ntioDloOJ.dDc:
For Office Use
?kb/O'-1
I
Checked for Delinquenci~ V-
riAl I flt
Dale of Applicatirn
, Checked for Historical Statu"
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