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HomeMy WebLinkAboutPermit Backflow Test 2002-6-10 225 fIIl11 STREET. SPRINGFIELD, OR 97477 . 1'11:(541)726-3753 . FAX: (541)726-3689 ~ ~ e,) ......--:4 I~ ~ ~ Assessors MF r ..~ " 14 V ~4 Owner n r &( e... ~j ~: Addreso ~ t~ .,)'r-1i ~4 ~ ~4 ~ ~ ~ ~ ..~ ~ ~ Q 5 ..~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ m . . / CITY OF SPRlNGFIELD, OREGON TRANS#:01-0009468 DATE:JUN 10 2002 AMT RECD:2 $ 51.75 CHANGE: CASHIER:061 City Job Number b 2.-60335--0 \ Job Locatior (,7 ( ~ JrlC) f e 5 I 70 L '< '+ ( I fA5 ') Tax Lot I Z( 0 a 537) Iv ('lc ht.,f p;\<L l<=- (+;/Is Phon" bgb~ 9r..rs-J" City {.;v... G-bV c-r-- ofL Stat" Zi~, '771:(0 J- . "',' - \ ~' ",,\;\ ,';'" "0'\ - ,'. ,,0\ ~ . , i,J,....... c..r IJ\l' .' ....t;J _ - 'e.\. ~ ,..f"..:J: '::l" BACKFLOW PERMIT IS S5I.75 (includes PermitFee:;~~~t~~~\I!~t~t~~-~~~ministrative Fee) .: .F" ,,\"\0" .~9J' \\,,~ ~\o'. (\ , '-' 'e\' \'(;0.\0 'l?<;oc\E~ ,..;,\0 \ , . \~\ "'r?;\~' ~\G o~'\ . ,~.~ ~.\~\c..,. ,\ ,',' . (\ v v\l ",(\ G . <:5.\' - ~,o\ ,u";",;;"O'~'2:I0~ ~ o'<;)\'.' ~ol'.. \~~\I.'l "~,,,,\. ~\.\~ ~C\_~ ~, ,~" ^v n'J /.' ~- "'...."-. \\\. ,(\'" ^o,. ...'1.... / ',_0\....' .:\~ n-c~,~,G\.:; O~..p. Ci. J\ S' ("'([i/(~f\.-q\'<',f ../.i:r . _9.~ 1 \.5v..~\\'..... \0\ . \'0' S c'" ~-oe\ G'&(\\"" 5' L, ( f~~ Phon" Contractor Information Contractor 1J6~ 07(1.. fjy~ ,'& S-- ()~?it Addre~s !XnJ/; "'.~ City f vtrf flf ~ State 61e. lit, :J-. '-I '] 0 Expires 0'-( 30 03 Zip tT? '-IoL ( Construction Contractors Registration # By signing this permit/application, I agree to call for an inspection once the backflow prevention devise has been installed and is visible for inspection (726-3769). I also state that all information on this permit/application is correct. Signatun' Dat" 06(00 ~ For Office Use Date of Application Ob ("00 L. Checked for Delinquenc' "0 c---- Checked for Historical Status 9ifb r Sban:d Drive CT:YBuilding FormslBackflow PreventionJ~2.doc