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HomeMy WebLinkAboutPermit Plumbing 1998-1-26 v . '. SP'IUNGFIELO II ~f i:o BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION d ,(' 6:'~: . /10 ,""', , 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 :::-::::::::~----~~~q~~~i\--~(i~~-~-~m______---- .- ASSESSORS MAP U: \ ~()f),,\)l 0\\ \j TAX LOT U: O~ .. - - OIINER: 'If/i'YS HcJ/f'7E> L. L, G. / ADDRESS: --;T::o. 4;j.e' - ~........-z ..d:'O}.R -":. PHONE lt/.C)oi'\6If2> 5~2 \ , /. '~ -.Ie '-- - ~ - ~ - CITY: 1)-17 ttJ_ ~ !fm~- ZIP: "Q -b ''9-% - -11-, ~~ ~~ Vl'& . BACKFLOI/ PERMIT IS $15.00 + $. 75 (S'JA~~~I~) + $'.45 (ADMIN. FEE) = $16.20 170 ~ ~o (~~ " ' , // / I <<II- 0'9 ~'9 .,..~ CONTR,{\CTOR: 1'1 ",?VS /7/") /W15~~,o~... ~;_ ~~,. . . r::O& - "u '00 1,,0 "~ ( ) - ADDRESS:;-r2/?~C-?> e? ~~J::~J.~v"'%-cit: 503 b?'-..:;?-s-g..:::::>} CITY: PO/7/4.n/l STATE: gif{~II/- ~r ZIP: '77..:2.'?' S- q ~ vI' ~ ~ CONSTRUCTION CONTRACTORS REGISTRATION U: _ ,q /0., EXPIRES:. 9'/ Y' f! >, . .:~ . BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOV PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726~3769). STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPL:_C~Tf:IlN i"I' n r ~ CORRECT, ?'.). jlX1tt 't1. ~x t /// . - OAr~~.7 ::~:-::-:::~:::~:::~---_-T~A~-~D\-~------:-~--:-------:::-:~ili()((A~ RECEIPT U: A~ - - ISSUED BY: --c1,tfnj TOTAL AMOUNT COLLECTED: < ~ I . ~D - FOR OFl'ICE USE ":' --------------------------------------------------------------------------------