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Permit Plumbing 1999-7-21
/ q , /Jilt'. :Jf3b(T -:- 5' L/ '3 /' ~ BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 ---~-----~-------~------------------~------------------------------------------- JOB LOCATION: !5~+ C3+,(~ '" ASSESSORS MAP #: / 7~ ~ ""?~ z.,3 OVNER: '&-L~Jt1>1).j PLAT?'"3 ADDRESS: It2Zo' ffl</~ L4~ /? "I I I CITY: Ldt:::; STATE: ' TAX LOT #: (f) /,4 tJ-O PHONE #~' 3 ~ '.<:; - <1-.3 -1-7 ~ ZIP: '77~/ , BACKFLOY PERMIT IS $15~OO + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 CONTRACTOR: _-;rn ~ lJ;z.l lIS", PUt#! k~, ADDRESS: ?Ut,..I 0t'fc};j.,~F/et:J 57 PHONE #: CITY: J~. STATE: ~ CONSTRUCTION 'cONTRACTORS REGISTRATION i: ~ 56 7~ {P<&9i,,~ /93( , ZIP: '/7fOf- , EXPIRES: 6:,//t:1/D'O , / , , BY SIGNING ,THIS PERMIT/APPLICATION, I AGREE TO CALt FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION " (726-3769) ~ "I ALSO STATE THAT ALL INFORMATION ON THIS PERMITIApPLICATIONIS , CORRECTB1a .. J ~ r - ?f /$~ /~T tu$c# /,a?~ "',' r, """." ~)MSC wAf' /~J~d8~77J7S~~( SIGNAT:t)~;(,i ... ... . .'. DATE.. ..... ...-1 . . .... . ... ~'" .... ..~t6tVb YtlYt W0t6 jJDff~S'r#~7lIIG{) ________:_~~_______~______!~~_~!!::!_'!!_E_____4) l/L22f~-j! -/& -/J DATE OF APPLICATION, ,?,/~/99 JOB #: '7~I).7:s' 6 RECEIPT #: ISSUED BY: TOTAL AMOUNT COLLECTED: , , --~--~------------------------~------------------------------~------------------