Loading...
HomeMy WebLinkAboutPermit Backflow Test 1997-10-1 : :~ .f'~ , , .' ..... .} ;:f ........ .:~:: ..... ....: ./.~1 .:\'.3 :..:~: '\ .'. c. c' -. . THIS PER~IT SHALL EXPIRE IF THE WORK AUTHORIZED UNDER THIS PERM~T IS NOT . ()R If; ABANDONED FOR COMMENCERA~LOV PREVENTIO~ DEVICE PERMIT APPLICATION ANY 1110 DAY PERIOD. CITY OF SPRINGFIELO BUILDING SAFETY DIVISION 225.FIFTH:STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- '. ' ". JOB LOCATION: 99 ~ ()LLJ A:JA'c..//,4A'LJ. .' ASSESSORS MAP 1I: /7 0 ~ ') "3 Lf-L/ (') 7 3o-il TAX LOT 1I: r . ;::::.. {;;::;.A' -<.. '~n.' J-I-o __-<- oS OVNER: ADDRESS: CITY: . 'i'j7~';,,,..f,:~ " PHONE 1I: I'J ,,/../- 2. It: ~ 0 STATE: 0~F. ZIP: :77y~ /' BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN, FEE) a $16.20 . CONTRACTOR: /lc.-L-"';:~~ J:'rf'A!g,;P/;P-' ADDRESS: ;),r?-.:A C v / o:9.v d~.tf'v 2. hi PHONE 1I: 93..r--;J';1,/U-- ZIP: '7?'r5-? EXPIRES: t,.- :3(!)-'?(i-- CITY: ~ ^" ....... 7?;1 STATE: tO~E; CONSTRUCTION CONTRACTORS REGISTRATION II: 1/:3 /'::Z 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. ;,L:X, .JtJ-/-;?.? DATE FOR OFFICE USE ------------------------------------------------------------------------.------- DATE OF APPLICATION: / () - I - '77 RECEIPT II: /) 7 '5 t./ . ISSUED BY: . cK'1 J TOTAL AMOUNT COLLECTED: / {p, :aD JOB 1I: q7 fJ (p 7 ::, --------------------------------------------------------------------------------