HomeMy WebLinkAboutPermit Plumbing 1998-7-28
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uO!leO!l!ION h\!I!ln U069JO 941 JOj J9qwnu AUTHORIZED UNDER THIS cIlt
9U04d9191 941 :910N) 'Ja1U90 a416u!IIeO '
^q s91nJ a41jO se!doo u!elqo ^ew nOA '0600 COMMENCED OR IS ABANDONED FOR
- WO,~g6l:l\fO 46nOJ41 0 ~OO- WO-~g6l:l\fO U! ANY' 80 l)b v /3t:RIOO.
4lJOjleS are S91nJ eso4~A.llIW~\Udijij:lWlijjijION DEVICE PERMIT APPLICATION
^llllln uo6eJO e41 ^q peldope SelnJ M_O~TY OF SPRINGFIELD
oi no^ s9J!nbaJ Mel u06eJO:NOI.LN~mDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: 6'7 RG ~,/ h--. / 1>.-L ,V'1-f) I ~ rJ 'h.telf-, I J '
. ASSESSORS MAP ll: It O:L 04 /; 4- TAX LOT ll: 03907')
OIINER: ~"m.,vo != ~ p,--t-t+,) L. AlA "f, I' I I
ADDRESS: ,?,'.-,pq l:::;7j~;", L"" .V'.t; _PHONE ll:
CITY: 'r r-I ""'\ C.-.\.JJ.
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STATE:
(l.f?
7w-z,~ ~ ~
ZIP: q' 7li 17
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (APMIN. FEE) = $16.20
CONTRACTOR: MA'oI '" t( ,'he-.
ADDRESS: ~ o. (0/0
CITY: rna'Y~f1 10....-.
CONSTRUCTION CONTRACTORS REGISTRATION ll:
La /V'>)-C' e:c.p P
~f"t.J ) to - k-Lh
PHONE ll:
STATE: (',)-V.
(,,74~
933 -:;2. 7<-1'-..-
ZIP: q7Yl~
EXPIRES: q /3J I q r
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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7~ .;;;. .P. q. 51
DATE
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_____________________________r~-!-O!--O!!-I-C-~-U-~E--_____________~____~____________
DATE OF APPLICATION(! IrK k ^ JOB II :gX(Y1~
RECEIPT ll: 02..;"{JJ(p , ISSUED BY: /J .lYk'lf../rdj)i ,
TOTAL AMOUNT COLLECTED:Jh//; .2D
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