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HomeMy WebLinkAboutPermit Backflow Test 1997-9-11 v .- . er- SPRINGFIELD I'!Oi\CE: EXPIRE lriHE WORK . THIS PERMIT SH~LL RMIT IS NOT AUTHORIZEO u~l~~ ~~EY~~~ DEVICE PERMIT APPLICATION O OR IS A6ANOONl:'tfT't' OF SPRINGFIELD COMMENCE 00 BUILDING SAFETY DIVISIOtl 225 FIFmYS1A?PtrY PERI . OFFICE I SPRINGFIELD OR 97477 INSPECTION LINE I 7"-37" ~ 726-3769 -------------------------------------------------------------------------------- 1)~..- JOB LOCATION: Q7J. mc..K.EN2..Ii;" eRE..,' slk"Nf'?FIEL1'-- , .' ASSESSORS MAP II: \io:')d..,,'-I,-l-o<:;"(.,oo TAX LOT II: ,- i<.u,,","~ O\lNER: 'GAR.L{ -r: "'5ALobt-l I ADDRESS: q7 ~ fhcJ'-.cN2./E ej2c:s,T\){(w€, CITY: sPr<..INGFIEL. D STATE: 012- PHONE II: iLJl -O"iJoh ZIP: ~/...j,7 BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: ANTHoNIi r,1)AWF~ - (Y)EA1X>I-7 Lf:!ND':::Lfl,oE S~i/las . ADDRESS: \,55 LLER~WATEl<. U9N€ PHONE II: lJ.b- o/1o~ CITY: S,f12/N61=IELD STATE: o~ ZIP: C()47?J . .cONSTRUCTION CONTRACTORS REGISTRATION II: 1,,1:, 9'1" EXPIRES: '-/-30-'18 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.' . . , .~..~D~ SIGiP/rv ~- /{-9'7 DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: GJ -11- q1 JOB III 0,,/353- RECEIPT u:m'l373 ISSUED BY:.n. rYI'2Iclru:uLG TOTAL AMOUNT COLLECTED:llp ~~ --------------------------------------------------------------------------------