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HomeMy WebLinkAboutPermit Plumbing 2001-7-24 '. . SPRINGFIELD BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION I' 225. FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 ------------------------------------7------------------------------------------- JOB LOCATION: ~'K (dL IJ~_ ~Y1Mj,'.eJd.. OJ2, (J (;1)' .' ASSESSORS MAP II: ,802.0'5 l:'-( " TAX LOT II: OIlNER: S'PWo.... H., M.e <; ADDRESS: $)31'Z?$S h..\.eYfrl'<<- ~, CITY: ,CH<..wdJ.. C[7475< o_~~-ao STATE: PHONE II: Of/'.1iwl ("<./-1) 9,q::; - 51'/{8 ZIP: '17<1Ol.ro lJ BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$1,6.50 . - CONTRACTOR:,c~ LaJJc.((l.P.iJ(-"-(~, . . ADDRESS: Q':3Dbb /2<'veLt1J. CITY: (' JIJ./At'. knl () h, J CONSTRUCTION CONTRACTORS REGISTRATION II: . PHONE 1I:..f<:;tj.I) qq.&'c:203Cj STATE: Ot'{JAOVl ZIP: 0</4g . u ~/ P C EXPIRES: 'Z - 2,--Ji'-'D2...-. 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 PERMIT/APPLICATION IS CORRECT. . ~~d~~ 4vfi~~ , . 7-2. </'-6l/ DATE FOR OFFICE USE .. -.. .-.~-._--.. - -- -------------------------------------------------------------------------------- ',.',- L'I". '. . DATE OF,APPLICATION:'07'3+G+ . -...-, (,,;,"3 of ". "0(-00 ~I q - 0 I JOB ". . RECEIPT #: 5; -I -10;0 DD ;o-lZ mrTltIJ CJ.. :;::I:: C':l o:t>u D ..co ___________~________________________________________________________________~~- .vG1~ I--l("")~oo m:I: 1--'1-0 ;:o:c....... C) ..zO"t'-JO" om.oc...oJ Cf"".rT'1(J100 ..........01-"0) ISSUED BY: /b ~ T'lt5 TOTAL AMOUNT COLLECTED: