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HomeMy WebLinkAboutPermit Plumbing 1998-4-15 " t@ . '" 'tIo?" f'~~ ~ P\?I:. \ \s ~o BACKFLOIl PREVENTION DEVICE PERMI'!:\~ATIg~p..\.\.I:.~ ~S?I:.?~\\ O? CITY OF SPRINGFIELD ~ I:.?~\\ I:.? \~ ~I:.\) r BUILDING SAFETY DIVISI~\S? ~tl:.\) \)~\) p..~p..~\)o i'i~o'(\ ()? \S 225 FIFTH STREET p..\.\ ."~,,,~CI:.\OF'F~t) 726-3759 SPRINGFIELD OR 97477 ~gPm:T~\'lN~E: 726-3769 ------------------------------------------------------~~~~-------------------- JOB LOCATION: J f q 'Z. C!.-t!3NT~1 AJI 4 L ASSESSOr,S lu\P #. I -(O:S2.'S 3L/ TAX LOT # 19D 0 OIlNER: ANz-1.cA-<r ( ^-i (/~ 1~"T5 ADDRESS: 6-5S'"'O OA f<-.tlLrD~T CITY: ~ ~l? u/4'( PHONE #: Lf-gs;- tf-7lJ STATE' 6r'C2? ZIP. '1'7 l.(-O ( BACKFLOIl PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: TVJ, k.) te..t tlE?Te-S pU..{j,.Lgt Aj 6- ADDRESS. (S?-:s- (~(/ (N (, ~ PHONE #: CITY: G-cJ..&EpJC STATE: ()~ CONSTRUCTION CONTRACTORS REGISTRATION #: (1 f, 'fr bt f - (1.{-4.L!- ZIP. 97l.fO<f EXPIRES C, /9 g" { BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOIl PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS CORRECT. IV-- /~ R ::f~::. - SIGNATURE -~ Y-/lsY'7 r DA'DE FOR OFFICE USE ::~:-::-:::::::~:::~-~-~-/~;r~-~-----------------------~~::-:~-~5?~~~-~ RECEIPT #. ()14 LlLlli TOTAL AMOUNT COLLECTED: ISSUED BY: { /1,-2.0 rI J/JA ~ k--- , ,