HomeMy WebLinkAboutPermit Backflow Test 1997-7-23
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OAIZED UNDER IF THE WORK
COMMENCED THIS PERMIT IS
BACKFLO\I PREVENTIOl<l DEVICE PERMIT APP.tm~4'1l~m.., ",OR IS ABANDONED F<ORNOT
CITY OF SPRINGFIELD ,} ERIOO.
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION:----LO()"S' rYe! url'J,'lI"d 1('1U:'.
, ASSESSORS MAP 1I: /7 ()3 d- 3 4 i
OIlNER: 'f-',^-+\A.N '\<., '0..rwVVJ <<-
ADDRESS: 35'13 elLEiZ t;;h q_ J)t?.,w PHONE 1I:
CITY: ~ J o,~./ STATE: 0!2-
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BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
TAX LOT 1I:
05000
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4,(5 - 617y.
ZIP: 97'70'8'"
CONTRACTOR: I-h /I cit y ,/ r ~/ a /'Y,.,t, In'1, Q:--l~7 rl rk J' ru
ADDRESS: :25,2:)(" St...{'H1AJ;;''fYIL.[J//. PHONElI: 'Q')t:)-')2J5
CITY: 1 J,plJl d-t'A 0 STATE: n1? ZIP: 9IJif!?7
CONSTRUCTION CONTRACTORS REGISTRATION II: / J '?7.? EXPIRES:
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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DATB I
FOR OFFICE USE
i:
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. DATE OF APPLICATION: 7-:;;;"3 - 97
RECEIPT 1I: O,J (/J I(/.L../ ISSUED BY: /J '
TOTAL AMOUNT COLLECTED~r b 11.0 ' 3D
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JOB 1I:
/ntJ_t".fi t:1 de
97///5'
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