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HomeMy WebLinkAboutPermit Backflow Test 2001-6-29 .. . . .. . . SPRINGFIELD BAcKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 :::-::::::::~-------~--~-';~--~~~~~:i-~~------------------------ ASSESSORS MAP j!: 170 323cf3 TAX LOT j!: O?I'~O OI/NER: . ~e- f2/D~ As' ADDRESS: CITY: PHONE j!: STATE: ZIP: BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50 CONTRACTOR: ~~.s.LJ ~a-41C,l ftf"'~~ ;J;:c. ' ADDRESS: PD. g >< 7C;;:vr ~ PHONE j!: CITY: ?C4~ <..-). CONSTRUCTION CONTRACTORS REGISTRATION j!: STATE: 6,J(. ~ ZIP: c'1'7<Yo I' EXPIRES: 0/-02-0,2 BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BAcKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. . ~Lf JL /~- SIGNATURE ~- ~ , ..~- ...... I / ..' "~~,A, /. DAtt I I 1/ FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: D 62-76 ( bG;!3 TOTAL AMOUNT COLLECTED: ::D = -l -l "" :;0 ::D I> ;0 -l :z: ("'J rr1 fTl CD ICJu# CJ:J:>O'"-l.. :I>Z..C=O (l')G1.......z~ ______________________________________________________-----------------------~~ I . t--l.. .00 f'..:lO rr1M ...00 ;0 "" 0 .. LoJ 0 f"..J 0"- o. . 00 O'-r..nOOf--L ~ac>"""co . JOB j!:OO-CI7bO , ISSUED BY: ~f(.. RECEIPT j!: lb~