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HomeMy WebLinkAboutPermit Backflow Test 2002-7-5 225 nrrH STREET. SrRlNGnELD, OR 97477 . rH:(541)726-3753 . FAX: (541)726-3689 € ..~ ~ ~ ~ Assessors Map ..~ ~. ~ ~ ..~: ~I ** ~ ~ ,__._h___ _ ___ ___ _. ___, ___ ____ ~ . Contractor Information ~ ~ontra~~~r~~-" "0> Addreso? 0dIJ () ~ ,\ p ~ C;'Yf-1A9e11P Construction Contractors Registration # g "o~ ~ i ~ ~ ~ r..~ Date of Application 0 ? () 50 L ~ ~ Checked for Delinquencies M . . DF::::;iX~rr:::Il"-r:!) ~ ~. . CITY OF SPRINGFIELD, OREGON TRANS*:01-COO~844 DAT~~JUL 05 2002 litrr Rht[)~2 $ 51.'/5 CHANGE; CASHIER:061 CityJobNumber 02.- OO'1{O-G" JobLocation IfJS(LJ FV\.v mpt1~[)W:J (7033CfZZ. Tax Lot 06/00 ~ Owner ( \f1r\ \(0 ']'()(\4( Address I (),~ (\o.....L lY'I'9(J...A,"}..JS Citv<~ fY\1J\~ "" J (0 J, ~ U Phone '1 Lf h,-ssq b Zip q'j Lt7'_ C\L Stat,. :")' -., '.f' '" BACKFLOW PERMIT IS $51.75 (includes Permit F~~; Stllte;Surcharge & Administrative Fee) ~.' ',\'iJ ,..'J.... c - . _'. ,.1 , WI ~ <,\}\o "",\1'>..:- ;... ,... ~\_\ ....e, ,,~,' ..\~- f"~' '.~--,.-c,,;:........-......~- +.-:-.... --'.r'~ ,~"-\-- _.- ,...- , . " .\' - ,n"'...' ," ,- ';- . . "':. ;,'._ _,\' . r. .:).... . 1 ", '-~-n,.-r )\....r:..:"'\...."\.~\...,. -..\.~~~;~' ,. - , ..' ~ ,'I'~'> '" ',' ~' ' -~::.lA V'\ -,',' -......., . i: .' ',. >~'2.LO Phone ~ ~ ~SlJ ~c., ..,- ~-~.C~.. . ,,(. State I)P Zip Cr7ljl5l..J '-/ /4 f 7/1 _ tQ\ ~~ires 91'J I 1""7... . A}"'\! -~~l"O ~l .~~\~? ~ ~,':)~?~~\.~ ~ Cb\ 'IS ~,t\'t>~~\~\. By signing this permit/application, I agree to ca~~~~~ \~ ~\~ow prevention devise has been installed and is visible for~~~ ~~$~~ alsO. e that all information on this p~eit/a lication is correct. Q~ Cb\ \.\~ ;\,'0\0 ;'O~tf\ ,~\. Signa ill II'Y1L ')(y) ~ Date~ -s- - ()z... I V . ( For Office Use t-- r--- Checked for Historical Statu. Shared Drive (T:)lBuilding FormslBackflow Pn::vcnlionl-02.doc