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Home My WebLink AboutPermit Backflow Test 1999-7-14 .. .' SPRINGFltZL.O BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFrICE: 726-3759 INSPECTION LINE: 726-3769 ~ JOB LOCATION: r~t.(~ ....-.... ;r "':: 1 . ,y"c. rI~,.r-::Z'-<"", ASSESSORS MAP #: l f)()~ OYNER: R,.....A'_ x1' ~o--.....s ~, ~14f).~ c::.r<'-<-s ;. .. .... TAX LOT#: O~<JJ) CITY: "">":'" STATE: ~ PHONE #: -Ji.-4- . VdaL2 ~ ZIP: q1fl BACKFLOY PERMIT IS $15.00 + $~:(STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: J-Iu..."....,,< ..:i=/f'/P~#//...,. .(' l,.,,,,.asc04/"'- ADDRESS: .;Lu:2:z..t ~"""~A?/ 100/ PHONE.#: , CONSTRUCTION CONTRACTORS REGISTRATIO~ #: STATE: tt)~ IJ'37'2- '7J~ 3':1../ J ZIP:-9~vJ'"7 CITY: J/c..~'~f ~ EXPIRES: "'I-3<9-4{/ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS V]SIBLE FOIl INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON T~IS~~~~MIT~Af&~ICATION IS CORRECT. 1110' inVOfificatio~es a(jop~on law re . 'l"ft/s. ::.C~; OO~~~~~2-o~~:~e;i r~~::~e o~~;~~ ~U r,. ~ '--IT~ caliin f11ay ob .0 thro liles are ti/fry c;:., '!~ Sft"l nUf11be [) the cer~.~am ('Q!J.~g~04~ 9. Set faith .~ 'I.I.~_ rrOrth~.r"",(/t.._,/S.xf',,- 'S2.nn,. . r '80 "t:D . ~U~09 ~\I'-'/09s: Cef1t(.Df'.l'Eegon U', ~'ie tel - 'u'es b D", y 009 /S l"ftts 1/:'.,., . "'flnD. tihtYiV e~hone jr ,()~/'> "'S" ,()~J'> ''Y~IA~ a"p'!:J"40flt,catio 't/O~ O-/~~"'41~~ . -,. 4), n S RECEIPT #: TOTAL AMOUNT COLLECTED: -------------------------------------------------------------------------------- 1-'