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HomeMy WebLinkAboutPermit Backflow Test 1998-7-13 'li( -- , " BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- . . JOB LOCATION: /f/I/)[ :ll"L~j'... (' ';- ASSES~ORS ~AP~: /)~~~~t:::-_""?""::l. OIINER:. !1/7.6 J) ./ ~/, V? .1. ~ . (' #'7 A7:; I.. TAX LOT~: C> :::?~-C> ADDRESS: CITY: PHONE ~: STATE: r-.b~.,c ZIP: BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: J/- TEe P'/'/_i/H' . .I J JJ/",,~, r~/~ .I .I PHONE #: 6' y~- 9-'7b? 2- STATE: bl/' ZIP: 7'7//of/ ADDRESS: ;!;;J.. .!?/y t!j.& IJ;:; CITY: Fr./r./.n~ .I CONSTRUCTION CONTRACTORS REGISTRATION #: t)''7r7 '7 EXPIRES:~A?~ ~57 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. ~/ ,._-;rL SIGNAT~ ;:/ (" ~~ r- ;--- 2-/J-9Y DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF Al'~8'j~: 7-/3 -c;JS RECEIPT U: /~t::'99 "/ ISSUED BY: TOTAL AMOUNT COLLECTED: / e:(. ';<P JOB II: '7~s.,c~ /?~~ 4'" '. -------------------------------------------------------------------------------- , - :, . _d -'-___... ~ , , City of Sppingfield 225 Fifth Stpeet Springfield, OR 97477 (503) 721>-3753 Tr.;;)nsact. ion nUlTlber' 030750 JOJly 13, 1998 1:28 PM ,Received fpom: VTEC PLUMBING I Cont.r'~cUO.m : FOR 1448 MAIN STREET . Addpess: P.O. BOX 41041> iCity: EUGENE St: OR Zip: 37404 -B'Jilding- 'Job t: 38081>2 : DescpipUon Fee PllJmbing St"te SlJr.ch"pge ,37. Adn,in Fee 15.00 .75 .45 Tot"l: : Amt. Received: Check t: 1835 1b.20 11>.20 Check Th~nk YOIJ, N~ncy M. ----- -------- --...-' .. ..,;. '. OJ .... ...... '" ':0:.:' ,.. '. ~ ./ < ,