Loading...
HomeMy WebLinkAboutPermit Backflow Test 1998-5-27 . . 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 --------------------------------~-~------------------------------------------- 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---. f 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. / '; <~~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 --------------------------------------------------------------------------------