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HomeMy WebLinkAboutPermit Plumbing 2000-5-16 -. .~ TRANS#:01-0001843 T' V'J'12000 6,50 NGE: CASHIER: 059 BACKFLOW PREVENTION OEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING. SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759. INSPECTION LINE: 726-3769 Job Location: Z S 3) ~0r+- Assessors Map II: ~ -;;;, 'J. 5 (I . . Tax Lot 3: 0;:;./00 Owner: Fa... \ ~ Addres s: '2 3 31 L~vf+ City: C::;r-Ar~ Phone n: 7'i(a"-ilP/l State,:'&- zip:3'1v1i'L L..."uw rUles ado .:.- ....:.., C'IU,lc" 'of,t'eat/()r f" . Olea bV~e 0 .. Jv... , nil(" _ .,Bn1cA ~l. ~on Ut., Backflow Pemit is $15.00 + $0.75 State"SurchargeA'_l'3,~J's. "ba)eset~IL VI:i() 1'0(/ 'Tie, (, 00911 OAR (tc 0, eal/irc' ',', . J:J/21!, GOP;e<' ,,,2-0(: Contractor:_ ~~l- I ~....J!...~ro;d;:.::;~>,^~ot:, C~f():,:::~:'(/':;)H , "~""..,.' -. ""VUI/ unlit' IVr_'~~' '-"C .Dhdne '#:-_:~OOg9.<=-t'1 ~ Address: \""\1'-'\ Co~ ~ City: ~I~ State: r.9-r . Constru'6tion Contractors Registration If: (/.,O'-1~ NOTICE: By signing this permitjapplication~s~~~~~to call for an inspection once the backflow prevention device has beem~~.l"e(PIcWt1!)iI?:#f;i!>le for, inspection (726-3769). I also state that albd~Tb~fIDQnV8gA~s~PpnH~a~ARfpermit is correct. MENCED OR IS IS PERMtTlS NO AN ABANDON T , ~ J ^ . ^ DA~PERI D. ED FOR VV~ ~/lc,/oO Uate ziP:9)~, Expires: IPhlJcJD , Signature FOR OFFICE USE Date of Application: ~~~)~O~ r Receipt n: lil.("\ Issued By: Total Amount Collected: J), \f, S0 Job n: 0()-(10J~:::r-:].-C\ W~, ----"}JoY--z . o +