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HomeMy WebLinkAboutPermit Backflow Test 2002-8-7 ZZ5 FIITH STREET. SPRINGFIELD, OR 97477 . PlI:(541)726-g75g . FAX: (541)726-%89 = oz.-aD bZ l...( -0 I ~ City Job Numb~r \ ..~ 67491 I,'-'l Job Location /:It'" Xy i1~r ~ ~ /70L 381/ I ~ Assessors Mi r .."(!!!!!j ~ t ~ ~ .."(!!!!!j i~ ~ Contractor Information 5; Contractor D a f <> f 4- .."(!!!!!j ?L( / :?> Addrers .:> b ~ (0)' = ~ ..~ ~ ~ ~ ~ Signature ~ ~ ~ ~ ~ Checked for Delinquencif'< M I -. ctlG . CITY OF SPRINGFIELD, OREGON Tax Lo' n6 ~o 0 Owner ~J uf iN ;ecc..<v1- , - -, 3:3 7J, \,frQ-k. Addres< (t I ~{ ( PY1:"Jc) 1+.1 Is. I'lJ .) I Phonf' bgb ~ '7lfSg C. . c.. . y 13: I' Ity 1/N .-jJ"/' ~ 9R Zir '=;7l.{O) l:::-v.J...y..frF Statr BACKFLOW PERMIT I~5 ~Iudes Permit Fee, State Surcharge & Administrative Fee) /6 ~ rtJC"t!J(<, 2bj A-."":: '- ":7--1- City 1E'^-1..r1S'T'f ~ State oY'l- ~)\NO\'.\\ Construction Contracto($~tionjf\t,') ~~\l\~iill.'r'c:. 11101 ~ _~,,~~r'{ S. _ 1'U\1;. l't:n .-r' \\i\~ pol ,. 0 \lNUI:." I" oot-it.u f\I" f>..\.l\\iO\\\l\,O o\'. \S f>..'Of>..~ By signing this permit/appli~\i~~\~e~11 for an inspection once the backflow prevention devise has been installed aD(fIi~~1lR,le for inspection (726-3769). I also state that all information on this permit/application is correct. \0 s'lou ,{"OIU\{9 \l\i\iW <;l0l' \a"~ v O{<:<;lon \101\\"\ O~.o{e -,'O,,\n0 a.{es9 0,\0 . ~\1'\ '. _.-:>u , ...\"S _""00 f>:- ,,;,. eS auv. ,nos<-' - Of'\l" ~- .,s O'J , \O\'.J {U\ cen\el. o\n~O\l<;ln \ \n3 !U\~ 9 .' a\\on , 000'\ "ieS 0 .,,,non .. ,^\\\\C . ...n.nO \ . _;1"\ cO", .._.... "ie\v\'" _..,nO 'i~ O~~~~ {{\a~~~\;!. \~~.f~\9,~c:e:~~; \lV~ca\\ing \\'v \n0 o{e~vO.~~'2...t."r' ne! \O{ . \S '\ .'00 .. nul'l'o e&3f7 6 z... Date of Application C 7J ~oc? 7'-1 Phonp Zip '7'7'l.{O..., Expires 6 Lf'3, 6 CJ 3 DatI' ~/~~ ....-- :D :3: -I _-I "":;0 :D:D Checked for Historical Statu< RirriEi5 0.. :::I:=$: C"J OD.. :D ..co to I"VCilI--l- ::c , .......r:J.oo.oo if1 ::r:: -.J 0 ::::t.1:D(J1 ~ "ZJ-IoI'-JO om- Of",.) Shared Drive (f:)lBuilding FonnslBacld1~We~ti~l!02.doc