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HomeMy WebLinkAboutPermit Plumbing 1997-7-24 ~' BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225. FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 67bb 'OJ Jue-b~ II~ ct:. " ASSESSORS MAP tt: if 0) 3~ t..J Lf TAX LOT tt: <6V3 OlINER: rM iJ- 0 }\)'), 12 r rrz~ n _ d-h/-L. B ),O}-( ~ ) 'h. q rJ t":J , ADDRESS :?f?J?Z-415 ~-tA. '<E -4'r:/ 'Y, rf PHONE 4: 74-'/- ~s5"' '3 6 CITY: )' '(?,-?cf A'~&A7C~ATE: rt/A , ZIP: 97478 // '~ .~ . , DQ JSto~ ~/' . BACKFLOW PERMIT IS $15.00 ~~~~~~~~rHARGE) + $.45 (ADMIN. FEE) = $16.20 I ~ Vi ~~"'1((' (:'..., VI) <? Q V(:';9 .,..~~ . CONTRACTOR: /jr' '\ l F ~ r ,()~~ "91& A,. ~(\ 1 ~ ~,., ) I)'\. ~ ~'11'Q 'VAl -,..,~ '~(:' . ADDRESS: ~ ~DO~I._i9~,., ~)lE tt: ' q 1.5 ~ 9 s) 9 " ;~o ,~. ~-t,.. . STATE: ..<'0.0 4'0/, ~ JOB LOCATION: CITY: ZIP: CONSTRUCTION CONTRACTORS REGISTRATION tt: ~~~C) () EXPIRES: -:J / ~ tJ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. ' A61/J} .. 'Wi ctl( ){,/ tt..l ~~ r/!JTURyY I --- '7~e.4 -'j7 DATE FOR OFFICE USE -------------------------------------------------------------------------------- . DATE OF APPLICAT,ION: ~ ,(fA. q '\ ~ ~ _.. ~ JOB 4: iWscg 1- RECEIPT tt: ~ \ (\<L"J:J...o ISSUED BY: 71\\t\().-J 0.. ~ ~ I \ {\ f\ - - TOTAL AMOUNT COLLECTED: \0 ' 0lJ ' . ~