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Home My WebLink AboutPermit Plumbing 1998-9-8 '. . BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225. FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- , JOB LOCATION: C; '?r-D (-10 II., "S+, . ASSESSORS: MAP II: / g () '2 ~2 ??$rJs XO:;:~~'l _ ,-".I.Qleq9n \'IeOle90 ""AO{\\'I OVNER: I 0 ,-,,,,,.I-ilvp' ..f.d.1>'/1_ ~<lle sH~ '\ ". . - \eS auvr ipOse \ -, p..p. 9~".-<' ADDRESS: jQ!lQJIi~"n C~~~4~t.Q)I9\'1~,.he lules '0'1 - NO\l(.-~9C.2._ti\JI.-J 'n c09'o- - \ele9nu,,- .r:-. I"\~p. "oJ o'o\al.. . \\'Ie ~"""~ /7 CITY:_ em,'" '~(., rna'/_ . 'I"O\e. . r~'i-"'=: Cll'<.. . O~' '-'\\'Iecel\\<w 'onl.l\\\I\)~;A) . callin9 \\'I60Ie9 332.-2.",Y-t"". BACKFLOV PERMI~u~es~i[n~i~~-~?95 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $l6.20 -So-fld.. O~. ~74 7 '8'" , TAX LOT II: .! 0 () PHONE II: (,8"6-0'7'0(, ZIP: '7 7 ,/4 'I . '..' CONTRACTOI~: "'ScL (~ k... S L..,_d~c.~ -+ T ..."::<>+.,,.... ADDRESS: 40b'?'O .AA<.l(____7.'r iL.., PHONE #: 744-7/35 ( CITY: . ~tJ+ld, STtTE: ~. ZIP: 'l7t17r . j '-NUl".. CONSTRUCTION CONTRACTORS REGI~~i1'fd#-~.; ~\()I f, 330 I f 2-17 6 EXPIRES: "if (3/ ('7 '1 ~O~\C~" II Srlp..\.\' ~~rI\S ?~?-\-II\I ~?- ( BY SIGNING TH~~)~B~~T(~r.~&~AA~~~AGREE TO CALL FOR AN INSPECTION 'ONCE THE BACKFLOV PREVEtffiION,I,DEVtCE II!MPt'JlEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). [0ALS~\~_TATErT~~.ALL INFORMATION ON THIS PERMIT/APPLICATION IS . CORRECT. (j()\'~'*' <11>.' 1'\:.1' ~~\'i .,lil). ~~ SIGNATURE' };.d~ / '" hr/ 'nS' DATE . , . FOR OFFICE USE ::::-::-~::::::::::~--~;r~-l'~-~---------~------------:::-:~~-~~~~-~ RECEIPT j;: II ~ /.J.J 0 ' ISSUED BY: "A ,fJ1 t1..--. . TOTAL AMOUNT - COLLEc:rED$ / ro - J- 0 --------..----------------------------------------------------------------------- ''''