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HomeMy WebLinkAboutPermit Backflow Test 1998-2-17 ~ -'...- .~.._- ~ .. SPRINe FIELD '..hI " ..~ :~~ BACKFLOI/ PREVENTION DEVICE PERMIT APPLICATIO:i CITY OF SPRINGFIELD ,BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIE::.D OR 97477 JFFICE: 726-3759 INSPECTICI LINE: 726..3769 .4A --------- ---------------------------";"'---------------__________ H' _ __________ .. _ ____ JOB LOCATION: 9t?o M~X::J ..7/"::' " ASSESSORS MAP I: 170 3231.f i Crf'-.!:..s~, .TAX LOT tSSO 0 " , " Ol/NER: 'f-.t<-"7;;.~~ ;?" J-/~ ,......-c. -S law requires you IV . ADDRESS: _' ATTENTION:Oreg~n...i..lhf' Oreaon l!t!I~Y~. J'H9NE I: _<;>~ follow rUles dUv,I.-- -, e rules are set!\\IITI,...E. . CITY: J FlM5-+? -o;,{;m:lr.ation Center. ~h~~:.~WPi\ll9~~c~m C::~A' I ~l(P'f~IIf:THE WORK 952 UUI-VV'V r..._.'9 lesoy. in O~R OU ~ay obtain copi~S of th: r~T#iORIZED UNDER THIS PERMIT IS NOT BACKFLOI/ PERMIT IS ~~~lIRR:lfth$ ce!iotE(lS1!'tgo:rei_&~,r~d5J ~:.(I.P!S,E.l'!3A:ll!lg')JE-!') $Ol~. 20 . b rfor the re 344) num e C ri51-800-332-2 . A~'" -'J,'/ Fi'R'I):) CONTRApTO!';: f-/ '-<--..-'/<.-<' ~ A"~<;"" /'4'" .,E / ;9~/dS'c:_r>-<.. " ADDRESS: ~ ,r-.J....2. C S?-A"";O.....&.A"..,?y .) A-v-c. .PHONE I:. /J..r-3:2./.r CITY: JA /,,~/?',1 STATE: (!)% ZIP: '}P'Vcr?' - . CONSTRUCTION CONTRACTORS REGISTRATION I: J /. f? :J.. EXPIRES: -!:L-J't1J - ,j1 " BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN:;PECTION ONCE TilE BACKFLOI/ PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE i:JR INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT, APPLICATION IS CORRECT. "L ~ < ;7.LZ'- J.2-I'/-3.;- OA',';'; FOR OFFICE USE ::~:-::-:;::::::~:::~--1-2-7i-7Tqr--------------------::.; -:~-qr~l{if RECEIPT I': ~3~' I ISSUED DY: 11. h/J,/ 1...-._ -_ TOTAL AMOUNT COLLECTED: .~ / (f . J-{") --------..------ -----------------------~---------------------- .. -----------". ------