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HomeMy WebLinkAboutPermit Backflow Test 1998-2-11 . . i\'lE wOf\\{ BACKFLO\l PREVENTION DEVICENlfi)R~:APpS#lJ\..df\E \f !-A" \51'10i CITY OF SPRIN1;~};!j:~f\tJ,\i i\'l\5 pEP' BUILDING SAFETY 1J\tvtSlottEO UI'IOEf\ ~OOI'lEO fOf\ P.Ui\'lO\'l Of\ \5 p.Sf>( 225 FIFTH STREET tJ,tJ,EI'IC\:O OFFICE: 726-3759 SPRINGFIELD OR 97477 CO 80~p~B~ LINE: 726-3769 ------------------------------------~---------~~-~----------------------------- g~(' ,~L.-I r.AA/JJ-.,-~~:--. ~~~ Drd {jrC.hl1r~ . ASSESSORS MAP #: l1012.< t./ ] 6 200 I O\lNER: . r-- <-Ci u..A"_ '~.. J.-I "''-'" -c. .s JOB LOCATION: TAX LOT #: ADDRESS: ~,.r b' ili/Y JQ/,-';',.";",,,U PHONE #: CITY: S ;01"fj~r< .t,_1 /1 STATE: {!),fF ZIP: '77v7? BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 . ~ CONTRACTOR: J.-I""AJ/<r"f '7,,('/1/'1-47"'0" ADDRESS: 2 .r~:L ~ S77fA ""re../PA', " L" " PHONE #: 9.r:5~3~/~ CITY: l/ '< /OI~ 1"?1- STATE: B1 A'E: ZIP: '?7~8-7 EXPIRES: Y-3o-:Jr- CONSTRUCTION CONTRACTORS REGISTRATION #: J /:? ? -::L BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO\l PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. ~rt:< ~ SIGNATURE ?-/I- J?- DATI:; FOR OFFICE USE ::~:-::-:::::::~:::~-~-l-;;-,~-~-----------------------~-:::-:~-C?-~/~-~~-- RECEIPT 11: ' nl '8' 77) ISSUED BY: i . Vh J k....- TOTAL AMOUNT COLLECTED: .'l111 . W --------------------------------------------------------------------------------