HomeMy WebLinkAboutPermit Backflow Test 1998-5-27
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225 FIFTH STREET
SPRINGFIELD OR 97477
~()1\C~: EXPIRE II' iHE WORK
iHIS PERNlli SH"LL iHIS PERMli IS NOi .
BA9-.~~iftJ tDi<~~I1',,@9J:T APPLICATION
r.I"O ~mii;~~'llP'ldlfGFIELD
COMMEN':'BUW~ SAFETY DIVISION
"N'( '600"'( .
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION:5f(\~~'e\6 !Jlo() ()aMoJL
. ASSESSORS MAP ll: 170 3)}. 4)-- ,TAX LOT ll: q 10 D
O\INER: ~ __~,~';..'.~ {jS,);C_ uJhc1Jilf'
ADDRESS: .C;-b() 04 ~O~ If_ .PHONE ll:
CITY: S.o''ir>-s.f,\o{ c\ STATE: 01f2---.
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5~'i-~'3
ZIP :0C/s (
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ~fIIl6 L.a.",.Js('~-
ADDRESS: (020 Ut:-S-t AI
CITY: .< oo:u.{;" j r) STATE: OJ?..
CON~~RD~I~N :O;TRACTORS REGISTRATION ll: ~~-~~
.PHONE ll:
7t:-( '7 -/()C;(7
ZIP~5 (
EXPIRES: ~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLO\! PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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<~~RE w
0L.-7~9i
DATE
FOR OFFICE USE
------------------------------7------------------------------------------------
DATE OF APPLICATION: <; / ').. 7 i '( r JOB ll: q~ DO ~ 'L
RECEIPT ll: (\3 (JJ3.J:, ISSUED BY: ~ 'f1/1,ttr-
TOTAL AMOUNT COLLECTED:l' I b - L 0
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