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HomeMy WebLinkAboutPermit Plumbing 1999-7-14 . . .- SPRINCFIt::LD I BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION , CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -----------------------~------------7--------------------------.----------------- , JOB LOCATION: /fr) JI-d-...r..L' ","..<..t ,ASSESSORS MAP lI:~n OVNER: I~.IP J.l-I......q ./-AI J ~ ADDRESS: .!3 \ 00 l'J).l\ (\f<"u (\ ~ U \{\ CITY: Cr J-1 fUL, "~:." "LJ STATE: , BACKFLOV PERMIT IS $15.00 + $~'(STATE SURCHARGE) CONTRACTOR: J-fu-~/ / ~/f' ":J.-lf/f/ <J/?- /~../ L 2~...a::J.sc-"J/- ADDRESS:-J.,..l"A;:;1 t:' r.l ,,,r~,s::A,,(-y--L(' PHONE 1I: 9z..J~J"':N<./ CITY: Ik........:T'A- STATE: nL ZIP: _9 !?vQ TAX LOT 1I:~ PHONE 1I: 1~1/i3(') 1101 ZIP: + $.45 (ADMIN, FEE) = $16.20 CONSTRUCTION CONTRACTORS REGISTRATION. 1I: 11;'572. EXPIRES: ' {/;.. 1'.:1'- t9 'lJ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE H~S~~EE~A~NSTALLED AND IS VISIBL~~,ri~PECTION (726-3769), I ALSO STATE THAT~kbLr.INFORMATION ON THIS PERMWT~l~~CATION IS CORRECT. II}O' IC"I/. {fI&S ~/~'q,; 'ERMITSH. 0090 "'/fy 9s. 01} 0&"0'01)/&'01] I. AUTHORIZE 'ALL EXPIRE IF I} C"i, !--O{f '.?-001,'I)le~ ;'06y"lI;,02'" COMMENC DUNDERTH/SP THEWORK f)/' /{f1J]6e~llt~itj, 06~010 IZO, <l'e~~e O;':'I-/i,s y, ANY 180 DA~~~: ISA8ANDO~~~~/S NOT /~, c'.., Ol'lh~$%r"/I}C^'I'ol{o,,/e,~,,'f!OI}u,o~/u 1-1 LPI1J~ OR "{St., Vl'e "VOt.~'es v4fy",SeI'ttl;iy DATE ' ',:; 1 '901}' e: II) Of II) 9s. fO , '<'100 UI}/,' et. e r 2-00/}'1,> -,)'8.:> 1I}Ii,e1e.o, tJ. il19S6 1, "<2., . vOl,,, "0/ ~ ' FOR OFFICE;1;Y.SEC"I};: " ' :::::;;:;:;~~~0~;:~~--A~~~j:-;:Qq~'l~ TOTAL AMOUNT COLLECTED: \ \l7 .:-i-) .~-