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HomeMy WebLinkAboutPermit Plumbing 1998-2-20 . ...- ,....,...... , . . ASSESSORS MAP ft: ~ . ~ \f'lO~v. 1:' . d?\~~ \f-1~ ~01 BACKFLO\l PREVENTIOti-\~k P.E~\.APPL~~ \S CITY df! \i~~tdbn~~1\\~ ~\)f-O~ BUILDING 1M~Jkat'ill'SllllN t-~p..~\)O~ ~1\\O O~ \S 225 FIFTH STREET f" l-l\"'~~C~\) p..\O\) , OFFICE: 726-3759 SPRINGFIELD OR 97477 CO ?()O"''{~€ INSPECTION LINE: 726-3769 ______________________________~_____~--~'ll------------________________________ /'-/'2 7:~ ,..v -I JOB LOCATION: 7L .... ...... / 7 ()), ~ c:. ()O (f) (o() I O\lNER: . /"'_ ~~- /--;f:up ADDRESS: 3 q / ~ Di /Jar/!... i<. Q{UJ. eU.?o\.R._ _ TAX LOT ft: PHONE #: ~Cf::;-L(199 ZIP: 9ivos CITY: STATE: 'f)/f_ BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN, FEE) = $16.20 CONTRACTOR: 340 ~_ Cn"'''7'A'~ ADDRESS: ~.&r /of'?~ CITY: ~.o,e/o,,(j,/r/ CONSTRUCTION CONTRACTORS REGISTRATION #: PHONE ft: ""~~/1J'7/ ZIP: 97Y77 EXPIRES: /p,/ STATE: ;.f?d , %.</S2/ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO\l PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-37.69').-- 'I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT . ',~ 8~ SIGNATURE 2. -20 -9~ DATE FOR OFFICE USE ::::-::-:::::::::::~---::>-1~()~~----------------------:::-:~-Cf-~()-~~~ RECEIPT ft: . 1)1 go~L/ . ISSUED BY: ~ /~ 1M ~ TOTAL AMOUNT COLLECTED: J {o - J-D ~ . --------------------------------------------------------------------------------