HomeMy WebLinkAboutPermit Backflow Test 2004-5-26
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspeetion Line
.
_ CITY OF ~rKll'\juJ'1l!,LU
Building/Combination Permit
PERMIT NO: COM2004-00625
ISSUED: OS/26/2004
APPLIED: OS/26/2004
EXPIRES: 11/26/2004
VALUE:
SITE ADDRESS: 2171 RANCH CORRAL DR
ASSESSOR'S PARCEL NO.: 1703244305400
Springfield TYPE OF WORK: Baekflow Deviee
PROJECT DESCRIPTION: Backflow
TYPE OF USE:
New
Residential
Owner: JEAN S FOSTER LIVING TRUST
Address: 2412 RANCH DR SPRINGFIELD OR 97477
I CONTRA'-luluNFORMATION I
Contractor License
SCHELSKYS LANDSCAPE AND IRRIGATI 006330
BUILDING INFORMA nON I
Contractor Type
Landseape
# of Units:
Primary Oceupaney Group:
Secondary Oeeupaney Group:
Primary Construetion Type
Secondary Construction Type:
# of Bedrooms:
Frontyard Setbaek:
Side 1 Setbaek:
Side 2 Setbaek:
Rearyard Setbaek:
Solar Setbaeks:
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
Deseription
Type of Construction
Expiration Date
02/2812005
Phone
541-744-7135
R-3
# of Stories: Lot Size:
Height of Structure Sq Ft 1st Floor:
Type of Heat: ~~.ft 2nd Floor:
A'rrl~'1~m:, Oregon law requIres yo 1'/,j<t Basement:
f~'b~~~Ji~J!,e.!.dopted by the Oregon ~'ilt...Garage/carport
Ener~ath:nter Those rules are ses l'Other:
N('s~fi~" ~d -'1~~!.I~:0 throughtGAR 95e -ant Load:
In OA.K ::>" uu . _ _ _, .h.o. rlIIQ~ b
_ _ "--- _';1":""_'" '-h."_'__
I DEVEEOPMENTlNEORMAiJ:ii:>N-ha telephone
, II'.' ,,1 'f' tion
'"~.... '" . unty Noli lea REQUIRED PARKING
umber for the Oregon II
8verlaYIY~\ler is 1-80Q-332-2344).
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
VN
Total: ,
Handieapped:
Compaet:
I PUBLIC IMPROVEMENTS I
Sidewalk Type:
MOTICE: l EXPIREIlp"ml!ot#lJ)'Mins:
THIS PER~i~ ~~~~R THIS PERMIT IS NOT
~~~~~~CED OR IS ABANDONED FOR
_::'1 n'3 ,;^V DIORIO\).
I Valuation DescriDtion I
$ Per Sq Ft Square Footage
or multiplier or Bid Amount
Value
Date Caleulated
Total Value of Projeet
Paee I of2
.
_ CITY OF .snul'l'-..1<IELD
Building/Combination Permit
PERMIT NO: COM2004-00625
ISSUED: OS/26/2004
APPLIED: OS/26/2004
EXPIRES: 11/26/2004
VALUE:
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspeetion Line
I FI'I'~ I:lWU
Fee Deseription
+ 10% Administrative Fee
+ 7% State Sureharge
Baekflow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
Receipt Number
$4.50
$3.15
$14,00
$31.00
5/26/04
5/26/04
5/26/04
5/26/04
1200400000000000812
1200400000000000812
1200400000000000812
1200400000000000812
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 Rl'ouirl'rl Ul'dions.
I BaekOow Deviee: Prior to eoverlng and provide a eopy of the test report on site at the time of inspection,
By signature, I state and agree, tbat I have carefully examined the eompleted applieation and do hereby eertify that all
information hereon is true and eorreet, and I further certify that any and all work performed shall be done in aecordance with
the Ordlnanees of the City of Springfield and the Laws of the State of Oregon pertaining to the work deseribed herein, and
that NO OCCUPANCY will be made of any structure without permission of the Community Serviees Division, Building Safety.
I further certify that only contractors and employees who are in eomplianee with ORS 701.005 will be used on this projeet,
I further agree to ensure that all required inspections are requested at the proper time, that eaeh address is readable from the
~~2>>}; 2~'''''''.' ,..~,.. u, "..w....J..j~m.... <>....,.. ~
Owner or Contraetors Signature / Date
Pa~e 2 of2
225 Fifth Street
. ,
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2004-00625
COM2004-00625
COM2004-00625
COM2004-00625
Payments:
Type of Payment
CreditCard
5/26/2004
.
RECEIPT #:
."~_~I""!!!~,,~' _. - ,,'.
~,
~.;
~ of Springfield Official Receipt
""elopment Services Department
Public Works Department
1200400000000000812
Date: OS/26/2004
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Baekflow Deviee
Minimum! Adjustment Plumbing
Paid By
MARK SCHELSKY
lIem Total:
Check Number Authorization
ReceIved By Batcb Number Number How Received
djb 000394 844203 In Person
Payment Total:
Page I of I
1:38:15PM
Amount Due
3,15
4,50
14,00
31.00
$52.65
Amount Paid
$52,65
$52.65