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HomeMy WebLinkAboutPermit Backflow Test 1998-9-8 " . .". .'" _. .. .., , ~ ' BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD ~ BUILDING SAFETY DIVISION 225 FIFTH STREET OFFICE: 726-375 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: g-~- /n<::."k:".M -::::1.1... ~<-.s/ ASSESSORS :-lAP #: J '/ V:?~, '2. ~ ~ OVNER: . "./--u~vf>... ~" 1#-.-__..5 ADDRESS: \) (C) \?Yx. ~4iL ~ CITY: rn~1\L BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = TAX LOT #: ~:?~~ 11M PHONE #:]14. ~~ ZIP: STATE: $16.20 . CONTRACTOR: J/UN I <:A TIf~c,.I4//:...r ..t .l;t};JLJ.r~--<-- ADDRESS: d~;>.A~ ~~L./f/f,/!..:r PHONE #: 93f-::'j~J- CITY: },4.,..,.......J rJ STATE: &vf? ZIP: 5'?Vtr;? CONSTRUCTION CONTRACTORS REGISTRATION II: / / .f?:2 EXPIRES: t./-3o-? J BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKrLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). ' I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. Pd ,,, SIG'~ }~ /~p.?~ DATE FOR OFFICE USE DATE OF APPLICATION: :l..:8'-9g RECEIPT jl: =j'/3~ ~ ISSUED BY: TOTAL AMOUNT COLLECTED: . /6.;2.- JOB #: ~R///? 4.a>z.-' - .'~~ --------------------------------------------~-----------------------------------