HomeMy WebLinkAboutPermit Backflow Test 1998-2-11
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SPRINGFIELD
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~~~~~~~\i S~~L~~~~~~p~~li IS NOi
BACKFLO\l PREVENTION DEVICE PERl1;l;'ff~'f1.WA~~g~ ~e~NOONEO FOfl
CITY OF SPRINGFIEL'tl". ENCEO Ofl
BUILDING SAFETY DIVI~M ~'{ pEflIOO.
~N'( ~800
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: ~i, "......, P C I.r ,- ~~...3' J! .,~. '......-<:
.' ASSESSORS MAP #: /""703 2.~4 '< 0200 I
O\lNER: . ~/"',,(~ Lf1 J-/tM--~S
ADDRESS: >>-;", h>:; ",,,( ...J/,... ~3. 801( 7t.j 2.z::;PHONE #:
CITY: s>A4:.~>..j'J-c.(KJ r::l<giI"LL-STATE: 6J,.,f.
1:q L.j OLD OfLCn(jr~
TAX LOT #:
7l/Lf- 2&& 0
ZIP: -; '; 7-)-? 9 7l(() /
BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: J./ u ...i7~ ~ IA' A'I e; 14 r;:. ... /'
ADDRESS:, 2.>..1.~ c:: ~/PI4",-,~A'", I....~
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PHONE #:
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ZIP: 'l7LI0'-'?
EXPIRES: '-1- 'J d -)13-
CITY: J/~M-_...J~
STATE: d,..f!
CONSTRUCTION CONTRACTORS REGISTRATION #: 1/.77 '2
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.
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DATE
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FOR OFFICE USE
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RECEIPT #: Z; .1 '8' 7 7 / ISSUED BY: 1l r fJlLtlA ~
TOTAL AMOUNT COLLECTED: ct / I/J .In