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Permit Plumbing 1997-7-28
.. . , . 'I . . 1(V 'X\<(..~ ~ ~~ \'0 A'~' I>o\..\..~~ ~'O~~<?I- \)rO<(.. ".,:\\\1 ~'O\"\ ~<(..'f...'fI. . o~€ . ~\J ~<(..~ -U~'V.. 1>o~'V ,,\"\\'0 ~ ,,~:iz..~~A....u t;'tf' PREVENTION DEVICE PERMIT APPLICATION 'iJ'f...\"\v ~'VV" 0'0. CITY OF SPRINGFIELD 1'1 ~~~~G ",\ ~~<(..~ BUILDING SAFETY DIVISION cO ~ 'V" 225 FIFTH S~~ . OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 SPRINGFIELD JOB LOCATION: 8'''1'.1 '1.,:-lB~0 tJ. A- i 7D33SLf.L TAX LOT 11: .2700 .' ASSESSORS MAP 11: Ol/NER: KAV Oy\/30,() . , ADDRESS: 8Z.LJ 1J. A CITY: Sl+1i1c1 HaLt> / PHONE 11: 1.(6h~) b'tt/-'l1Xh - . STATE: ()~. ZIP: BACKFLOI/ PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE~ = $16.20 CONTRACTOR: \.bs ftu-m, fn,J, ADDRESS: i7l VAtJ ~ CITY: 'EucrBIViT CONSTRUCTION CONTRACTORS REGISTRATION 11: PHONE 11: 485-CJ.S-C I ZIP: 97i.flJ Z EXPIRES: .; ~-1/-'18 STATE: lH€. t./ U!3OS" BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOI/ PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. ~".'~ ~ ,I.- ~ 7- z,s-9/ DATE FOR OFFICE USE ::~:-::-:::~:::~:::~--~j7~-~1q;~--------------------~--:::-:~--~~~-;~~~- RECEIPT 11: _ () 2 ('2.... 'R <(0.; ISSUED BY: ,I( .!Ih ~ TOTAL AMOUNT COLLECTED:~ s;, / (". J-O -------------------------------------------------------------------------------- .~