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HomeMy WebLinkAboutPermit Backflow Test 2000-9-11 . . 187 000 AMT RECD:2 $ 33.00 CHANGE: CASHIER:059 BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD 1r BUILDING SAFETY DIVISION 225 FIFTH STREET OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 ------------------------------------7------------------------------------------- JOB LOCATION: 7r6' 7 ~c:../<-.. ~ '-;? ,-'., C~s;-- " ASSESSORS HAP 1I: 1:ro3;;)...SL./3 TAX LOT 1I: O"C),OOO OVN~: ~/~/f'-<-' f M..............s ADDRESS: ~ ' CITY: S/ft:n,-"'..c~t' L:J . ./ PHONE 1I: STATE: tJr(, 'OOIl:l3dAVOoiH ~;r,~:9>q;'.f) . l:f0:! U.:lI~UON\f8\f 8/l:l0 03::JN3V1JVlJO::J ' 10N8'1IVIJ!:l~,.l8IHJ W' ~-- BACKFLOV PERMIT IS $15.00 + 1.05 (STATBl:lSURCHARG~) + $.'4'5N(lAnKIN'DWBIN =$16.50 " VIVI.:lH.Ldl.:ll:fldX31llfH8 IIVIJl:l3d 81Hl CONTRACTOR: J-/u",7~ .IA".fJa~~' j lJ'J/-/dSC;9./'..... -2?...:..iO/1.0i\l .,/ ADDRESS: ;) ()22 C:' ~lL-L.dAl" ~~/ PHONE 1I: ~ STATE: t<'JrC CITY: Ik",,-~ ZIP: '7/ y;r> CONSTRUCTION CONTRACTORS REGISTRATION 1I: A~n~l? . . EXPIRES: $/- 3'0 -II> 0 fol/owru/es' ,V'''~'' il" "0ut'e' ,01, , II' , adopteo OY!he Oreaor. '"11. BY SIGNING THIS PERMIT/APPLICATION, I , a~~n&AntteF.OR1~ (~!~~!9.ij~9NCE THE BACKFLOV PREVENTION DEVICE HAS BEEN IN . :MW1'1L!1)m~Yh n~..~ !N.~..P~~ION (726-3769). I ALSO STATE THAT ALL IN '1' nuwarllre5n~~TlA~PLICATION IS . CORRECT. ' calling the Center, (Note~h:~~";D'hUle. // numberfortheOregon Ut','/,', . or,<, r P". \ \lOl'hcarr,;f' .::l I'" l.t'l'\ '''' ), -,.". ",l.'l, /_//_t:P ZJ DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: q, ! 1. 0 r3 RECEIPT 1I: ~ I C?~ ISSUED BY: TOTAL AMOUNT COLLECTED: .:iI. [h,50 JOB 11: 0 0 - (j OLl It I S- 0 3 W~ , . --------------------------------------------------------------------------------