HomeMy WebLinkAboutPermit Backflow Test 1997-9-11
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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
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JOB LOCATION: Q7J. mc..K.EN2..Ii;" eRE..,' slk"Nf'?FIEL1'--
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.' ASSESSORS MAP II: \io:')d..,,'-I,-l-o<:;"(.,oo TAX LOT II: ,- i<.u,,","~
O\lNER: 'GAR.L{ -r: "'5ALobt-l
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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
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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.' . .
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SIGiP/rv
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: GJ -11- q1 JOB III 0,,/353-
RECEIPT u:m'l373 ISSUED BY:.n. rYI'2Iclru:uLG
TOTAL AMOUNT COLLECTED:llp ~~
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