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HomeMy WebLinkAboutPermit Backflow Test 1997-7-23 . . r~E IRE 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 -------------------------------------------------------------------------------- I 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- o BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 TAX LOT 1I: 05000 I 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. ' ' I I ,,~ t#r~ ~-2'\- 1/7 DATB I FOR OFFICE USE i: -------------------------------------------------------------------------------- . DATE OF APPLICATION: 7-:;;;"3 - 97 RECEIPT 1I: O,J (/J I(/.L../ ISSUED BY: /J ' TOTAL AMOUNT COLLECTED~r b 11.0 ' 3D , JOB 1I: /ntJ_t".fi t:1 de 97///5' -------------------------------------------------------------------------------- ~