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HomeMy WebLinkAboutPermit Plumbing 2002-1-8 (2) . . SPRINGFIELD ~ I BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD COMMUNITY SERVICES DIVISION - BUILDING SAFElY 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: J t:: () <.) )- /4 Assessors Map #: 170 s."'3,.b3 Z Tax Lot#: ClGs-al ,0 .,,':' <'$:\~ (';)1'0' ,j" Fr::,'" 11:->/'\ Ai ~:J;!'I:"S~~":'" Phone#: 5Y(- )tjJ, -'it?? ",:-t.: ,........" 1l'",,"-!l. .~.... ",(I) .1 - ~ .'.J c:.-,~ J.;-.r ":-.." ~ City: ~.., -10_ 1/ ^,'bStite,'Y" O/;~"_if'o_~o Zip: '776!(tf , '~v '0\ (D ....,. O'\'- .~_. . ~Q' 1 ~":> '...)0 .)~ c". ......ra o~ . BACKFLOW PERMIT IS $51.75 (incl&ies~PeTIffi:t:Fee;;Stat~ Sfucliarge & Administrative Fee) ,......;- .;',J .... ~.. ,..... '.C' .x~..) .-"'~ ...~w. 11;' ~0 .~... _~,,) ~~ ,,:. fj;' 0. ~ (........ r,)" ,:..... 'O:"-'S;' \.). -' .' /'f:.,'-'" ,0 ('0 A' .....j) ~ .... .,.'., U~c f~ .;:'s" ~.J Q' <'9 i'" ~;::: .... '-'..;J ~ -,... ~..\ ...~. /'J-J \ .... ~l -'. ,""" "" ....~. ",.. ^'<:" ".)~." ,.~fJ' q).J ",.' cr eo" /- ~u..; '" ,~~~.~~~~ -~ ?-'1 z.. Uu. - ~.nlli-,"'..~~.ci,",0' Phone#: 'I .(<h) n .~ O]"~.. ,,' Q(;' _ ~~ / ~~~ ~ ~~ City: I7w<e... ....,State: OR. ,~$,:~ /7l(oZ- Construction Contractors Registration#: Y / ~ 0 (' EXPires:~<SJ B . . thi rrnit/ 1- . I all fi . ~~~. (::..f3 z~:...x.C;;, .r.' . d . h Y Slgrung S pe app lcatIon, agree to c or an mspe \1l'~v{!)l'.v{entIon evJ.ce as been installed and is visible for inspection (726-3769). I ~u~l't::m on this pennit/application is correct. (), ~- ~a ~ ~ ~ _ ..!I ~&~~"co<;::,~, L-r~' <--Vj.v.-/ ' ~ 6/;6 i!/o 2- Signatlfre / Date / / FOR OFFICE USE Owner: .J:.,.....~"'1 1 E)I<> ~.rJ \ ~ ,A-Q.-lc- Address: / /, (; z z. y Contractor: Address: Date of Application: 0 I / () 8 ~ L / I Checked for Delinquencies: L-- Job #: 0 I - 0 I 3" ~ ~ - 0 I Checked for Historical Status: ......... VALIDATION: :D :3: -< -it:::, ::::0 :D :D ;1J -I Z rr1 rr1 (J') CJ... '** (J OC-.,ju :Do ..:DO c.o /'..,) :z: I-L :c I I-In~oo m::r:: coo ;:0 ::D Con (:) .. :z: 1-....1. t...)-..::I QQ- 00'. cr--. rrI -.J 0 ....0 1-.1... Ul h) CO