HomeMy WebLinkAboutPermit Backflow Test 2000-9-11
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187
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AMT RECD:2 $ 33.00
CHANGE:
CASHIER: 059
BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: '?r1O/) ;,n~.kC._, ~ .I"'; Crk-5 r-
. ASSESSORS HAP 1I: 11-()~ (;;;2,':,L1 ~ TAX LOT 1I: Od-/) 0.0
OWER: ki.ll.c...f... If' A4. -no ~ ..s
ADDRESS: I
CITY: Sa~J?,~/.d
PHONE 1I:
STATE: t9/f:.
ZIP: 9/'~7 ?
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) c$16.50
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CONTRACTOR: J-/U~A,.(' I'/f,f!,_Vlf:",,_J ~'"loJ.~fC,
, '. -: --~ "'''''VUUN'"'S'"'S . - -V'./\IV.V
" A"lIJo. ,..1 V V II:!OQ~~"i1' .t:l
ADDRESS: ,2,r:2.2.< <,) I A~~.,YrwIJ.IVlJkl;1..C'I,,, .._ PBONEI~II.:Jn~.r.I~;r~/.J-
>I!:IOM 3 . .. .- ~-:JU'VII CEZII:!
CITY: 1/.:-~f~(;;<9- Hl:{HAi!E::a.:i9~C'I......_OHln\t ZIP: ~:::>~9-''7
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CONSTRUCTION CONTRACTORS REGISTRATION 11: ) / .,7'2 . :3~':.!.~~JXPIRES: 1.// 3~ <17/
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. ATTENTION:Ore c . ". '. .
fO!/~wrUlesado g /. a~ aC;vICS: ~'.
~~flcat;on Cent:,t~~ by the Oregon UtI/II .
~~9~~952-001-0010t~~~~g~ are set for.
"'oli:_~~,may obtain cnnie~ of AthR 952-00' /' -/ /- ~ 'D .
...."'. "'''':mfar (N t' e . (DA'l'E
numberforthe O' 0 e: the telepnon. J
. regon Utility N" "
, Center;s i .P'1n_1~0-:?,.14~:~f,cation . .'
FOR OFFICE USE
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SI
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DATE OF APPLICATION:
q. \ \. ()O
JOB 1I:
oo~ OO~ -:t-(- 0 ~
RECEIPT II: . ISSUED BY: ~) 1\
TOTAL AMOUNT COLLECTED:-l1.l6 ,SI?
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