HomeMy WebLinkAboutPermit Backflow Test 1998-6-9
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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
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ASSESSORS MAP @:
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X""/ 2. Y)(/~j(...^, -z.'~
r7 (J~ 2 2, t-/ 3
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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
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DATE OF APPLICATION:---!fl-tl+-q (' ., JOB <<:_q ~D(~
RECEIPT @: D3DJ-).j-f ISSUED BY: ff l1/1~ . -
TOTAL AMOUNT COLLECTED: Ch /10' La
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