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HomeMy WebLinkAboutPermit Plumbing 1999-10-6 . . BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISIO~ 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 JOB LOCATION: .~().3(J hFflEJA)A!L L(),~ SnIN('1/-li::;L\;--' Cf7<.f11 , ASSESSORS MAP II: J 7 03 d-d- '70) TAX LOT I: o,~ SCD') e. OIINER: h'1n'\) INI1'J~IKII:-' t'J>.../=-""T Uf\JiilN ADDRESS: ~O~() - GATI-c"7A.JA(! Ln~ CITY: '::J '\->R \ N hFi l=:C \'--,. STATE: PHONE I: J L/ I-:J (,(},<::: ri\2... ZIP: 914// , 'aQ/~3d.A.Va8BLUJ\t. . B~lP:J\l.Jd'6ilW8h18 Sl,~. 0 +' ~'''/5 (STATE SURCHAR~~) t+. $.45 JADIiIN.w FEE)rl'" '$l6"r2O aa3:::JN3V1JVlJO:::J follO\ll' r"'eo arlnr"'f 'lv''1e (Jr8C'on u11a.y5D lONSI1WII~3dS~Noa3Z1~OHlf1\;l ,~~.;;"'?t' :~ ~ " 'W'c r "'>P ,C ,08',1r>rth )f~~~P!a - '\t 9fll'~ LEN"',~(A'P6:, :S672.V'/~, ,-_<;;"', r'b, < -'''~.{'r.1- . I ~""U""lrfJ.. \ ., -oopo Yo' ...,,,,, ch'E"rLjl~'j,f oh'(f ,IIo.()S by ADDRESS: iSS' CL~trnli~,rnJj;.I),:'R LANe __"..,_ PHONE)I: "Jrl.D';-c""l0,,~, ............. .~. II = ..' ", . CITY: S ?i<..1 N r-.(:: I eLf-..... STATE: 111J"(~ '1",0 2'?: ~:,~;I~I~:~:i~i1-'7 >( .....' ..cONSTRUCTION CONTRACTORS REGISTRATION I: Lc..:f'-, ~ hi, qs:- , - EX~~RES: ~/ Jr)()OO BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERHIT/APPLICATION IS CORRECT. . A>-h. S'~A~RE /"Q _-/"7 olllh /;f FOR OFFICE USE ::::-:~-:::::::~:::~--{(:)~~~-~----------------------:::-:~2:f~-(:)-I~~ RECEIPT I: 03579:"..5 ISSUED BY(\ macha.d CJ - TOTAL AMOUNT COLLECTED a I (/) ,5() ", --------------------------------------------------------------------------------