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HomeMy WebLinkAboutPermit Plumbing 1998-12-1 .~~:. -.. BACKFLO~ PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIE::.D OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-,3769 " .. ------~--------~--------------------~-------------------------------------.------ JOB LOCATION: It ztl ~'t'I1,rl'nn/~/ If/vd " ASSESSORS MAP #: 1703)) 1 <I , TAX LOT fl: tJYs-o/J O~NER: ';i(/~1/ f /rllfr'd 5q~A' , ADDRESS: /6' 70 '~~'I-~1t!'A~O/?/t/d' PHONE #: .(' _ ~' V'J ,e ' on U\\lM.... - p. . CITY: J-Or..~\Idfi~, "tne~::;fDse~~:'/ ~ r ZIP:f'7~7 ,- ',.... u\eS aou 1'nose fU Po 952-00 . . 10\\OW f. centef. oU9n 0P\ fU\eS b'/ , " BACKFLO~ p~~~~~;~~~n~ases~~~CHARGE) + $.45 (ADMIN. FEE) = $16.20 \n OA.R'lOU roa,/ obta 'Note'. tne ~~ot\1\Cat\On , 0090..('J'....Ail centef:~dU.\\\\~'/}... ,. ,/ . 'qoNTRApTor): c~W'~"'O{~LO ~344~~ ~/ q~ ~ t' f . ADDRESS:" '1J2.~'OJjl3f \s ~~ - .PHONE' #: 7 Z~ ~G 5' 2- ~ CITY: >(/r/rhqJ;,~/d STATE: #,,.... ZIP: r7o/'77 CONSTRU~ION C~NTRACTORS REGISTRATION I: /'Z6 t:1?~ EXPIRES: /1-~~t7tJ . NU liCE: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO cli:!!.Sf~fIAIN ~G~~tfiE t)N'BrtE1MnRK ~~~~:~~~9~~EV~N~~~~ ~~XiiET~~i :~~NI~~~~~~i~gN~:~~NI~~l~9~~~~f~~NOT CORRECT. . \,.,UlVIME: Gt:U OR IS ABANDONED FOR . ANY 180 D,"\Y PERla/), ~~ SIGN~1<< ~~~ ". ,. /? -/' ? r DATE FOR OFFICE USE ---------.-----------------------------------------------------------------.------ DATE OF JlPPLICATION: 1"1 Ili'if , ,f RECEIPT t:: J 32. I t:f 7' ISSUED BY: /J JOB #: Cffli~ J 'p(f ?J w TOTAL AMCrUNT COLLECTED: /10; 2 0 --------..------------------------------------------------------------------------ ' . ,j