HomeMy WebLinkAboutPermit Backflow Test 1997-10-1
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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
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JOB LOCATION: 99 ~ ()LLJ A:JA'c..//,4A'LJ.
.' ASSESSORS MAP 1I: /7 0 ~ ') "3 Lf-L/ (') 7 3o-il TAX LOT 1I:
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;::::.. {;;::;.A' -<.. '~n.' J-I-o __-<- oS
OVNER:
ADDRESS:
CITY: . 'i'j7~';,,,..f,:~
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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.
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DATE
FOR OFFICE USE
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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 ::,
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