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HomeMy WebLinkAboutPermit Backflow Test 1998-6-9 . . BACKFLO'J PREVENT~Pl~~;~ ~~l,l,l1iIE~I!~fZ~ORK ~. ~ . CITYr~ mlfN'GF!rftb NOT BUILDII}.G 1%ji1l~"trPJlIMI!R>TtlIS PERMIT IS . - . tJ , S ABANDONED FOR ' 225 FIFTH STREET . COMM~NCED OR I OFFICE: 726-3759 SPRINGFIELD OR 97477 ANY 180 OAY PERIOO, INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- ASSESSORS MAP @: , X""/ 2. Y)(/~j(...^, -z.'~ r7 (J~ 2 2, t-/ 3 ~y(1~s ~ JOB LOCATION: TAX LOT @: 1001- O'JNER: 'CJ7 ____ k1 ~ z u /P ADDRESS: '8'V A - J-n.-<-J<;:.^, ':2.,:"" c..f'~ r- CITY: ..s,l?~""..f?,-<.ud STATE: .PHONE @: &.-t? ~!Hr- '7;1.9<2... ZIP: 9'7 v8'-7 BACKFLO'J PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRAC'::OR: J-)~",/ <:,,(:' I,.f',(:';~/ coW' d' ADDRESS: :J,r.....d-.C s-r-~H/~,,(/fv )*", ~ CITY: -1/:. ^'-<- I, f STATE: 1~",~t!~~ PHONE ll: '7 3 u-:5 :2/J- ~l 6J/E ZIP: j}7Y8? CONSTRUCTION CONTRACTORS REGISTRATION. @: I. J. ? '? 2 EXPIRES:. 'Y-.lt9-:?J BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO'J PREVENTION DEVICE HAS BEEN INSTALLED AND.IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. #/~/ r/~~ ~-:7-Yr- DATE FOR OFFICE USE ----------------------~~-7~-/~-------------------------------------------------- DATE OF APPLICATION:---!fl-tl+-q (' ., JOB <<:_q ~D(~ RECEIPT @: D3DJ-).j-f ISSUED BY: ff l1/1~ . - TOTAL AMOUNT COLLECTED: Ch /10' La --------------------------------------------------------------------------------