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HomeMy WebLinkAboutPermit Plumbing 1998-5-4 ~ BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET. OFFICE: 726-3759 SPRINGFIELD OR 97477 " INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- . . . JOB LOCATION: ,J..JlfiS' .~~. ) . ASSESSORS MAP #: J 7 0 3 j. -3 "3. 0 OYNER: j 0 k", o~ !(..:rt, ~vi,,>, "Vtl-r ADDRESS: ,;L?95 'Co-&rte Dv-l~ ~. CITY: ~,{J l-" vt.-.. J i, e /J,,' STATE,:' ~~. TAX LOT #: (oo--tJ a- PHONE #: 7 cr:? - 9 6/ c/' OK 'z~P: 97 If:7 7 , 'i ' . "\~~e .,,, . .'. '; BACKFLOW PERMIT IS $15.;00 + $.75 (STATE SURCHARGE) + $.45(ADMIN~;FEE) = $16.29 CONTRACTOR: cCe ! r NtiTlGi:: n.Uc- DCp'lAIT n/ " ... EHONE #:' . .#. -: ~;:'FIU Att1:XP/RE Ir-IHE WORK CITY: AUTtft)A1ZED UNDER THIS PERMIT IS'NafP : . CONSTRUCTION CONTRACTORS REGISTRATIONCQ~MENCED OR IS ABANDONEDJMa:RES: , . ; . ~~ ItjUUAY PERIOD. ' . ADDRESS: . I I BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL,INFORMATION ON THIS PERMIT/ApPLICATION IS CORRECT. .! . . .' .j~."r SIGr:;l . 15 S/tf/9 f DATE . - FOR OFFICE USE -------------------------------------------------------------------------------- . . DATE OF APPLICATION:. . /lIvap- l/ pi. 19 r? RECEIPT #: ~ OJ (p;..j 7 ISSUED BY: ~B #: c;gO!f'2'3. d WtJ'. TOTAL AMOUNT COLLECTED: / b - ZcJ -------------------------------------------------------------------------------- ~ ~.,..;. ~ ~ . i .....'.y. . '. . I', W -~ ......! .t. , ),' '~, . ~q -----.. " ,.tr~.,'~'" I' J -:.-~ I r .." ~ -- -' /HI',}"":;"'" '\1 Ji.Wl:{'::\ ..". 'I" '--Q . T (', .v\::~:..:(~r:,lt'j;I~"':::~I~"'~':!'\' 'i~ .,:,[1;.,",,' \~"""" .~. .:.\ ~t:"j.;\J::t: ,~;~:,;~: r~;:,!\ ." _, '. _ '."'!: :!....l'...\.\'~'~.M./.'.';'\ .,J-.~"'" 'J ~.....i.df;.J\.,h,J i. ,,~ :)l;r3'~i y {J/t {';~:~ r \ft~l\ \ y -n- lilv'. ,/. "I: ,. '. J" ,,'" "oJ ~ ", ", . , " "..J :". I _i