The URL can be used to link to this page

Home My WebLink AboutPermit Backflow Test 1997-10-1 ",'. " '" , ...; ':i ,~ (~:!. ..... " .... J1 ....: : '.~ ....J , , ".:: "- ,', " " ,,'f ".' "- . . SPRINGPIELD NOTICE: THIS PERMIT SHAll EXPIRE IF THE WORK AUTHORIZED UllYi.eKlfm9 Abo.~It>..~DEVICE PERMIT APPLICATION COMMENCED OR IS ABANDONJ:D-~ OF SPRINGFIELD , ' 'BUILD[NG SAFETY DIVISION " 'At<!Y 180 DAY PERIOD, ' , 225, FIFTH: STREET OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 .~~----------------------------------7------------------------------------------- -, JOB LOCATION: ?'r3 oL.tJ ~,.{/t:...)).4,.1'r-:J /70 3 2 ?> '-f.;).. 0 / 600 TAX LOT 1I: " ASSESSORS HAP 1I: [ , ~U.IIA.,f-<. '/.?" J-I b"""-"...5 OIINER : ADDRESS: CITY: _ ~.:r<; h-<-l r:J PHONE 'lI: STATE: t!'/rfp. ? "Y'/- 'J. r; r:: 0 ZIP: 7''71(7') BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20 CONTRACTOR: JI ~'" -n,,,<> T:A' /f?, ~ ~ ~/ ADDRESS: 2.1-~;l.b S'/A'~.........6.4-<,-, 1. iN PHONE 1I: '9 ~ .r:.. ;r ~ I J--'- orfE' ZIP:9 70/' g-;? CITY: 7/-<-",/--<::/.4 STATE: CONSTRUCTION CONTRACTORS REGISTRATION I: J / ;$ '72 EXPIRES: v- 3 (9- :; r 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. ' ' ~ 1t9~/-:7/ DATE FOR OFFICE USE ------------------------------------------------------------------------.------- DATE OF APPLICATION: / () - / - c; 7 RECEIPT 1I: 02.7Cj&/ISSUED BY: oj/(..() TOTAL AMOUNT COLLECTED: I to. ;)..0 JOB 1I: Q70 10 ~L/ -------------------------------------------------------------------------------- , , '