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HomeMy WebLinkAboutPermit Backflow Test 1997-10-16 . .. q\C~ EW~EWO~ ~O , . SI-Ifo.u. EY-I'IR Ii IS \1101 1\'1151'ERtAI1 \IIOER ~IS I'ERWI fOR fo.U11-10R~VkO~S~~9 DEVICE PERMIT APPLICATION E\IICEOO~ CITY OF SPRINGFIELD CO"^~eAOP.'{ I'ERIOOBUILDING SAFETY DIVISION . 225 FIFTH ST~' OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: 1 t'l "3~ f) (.c) t!),f~ ,L-!;4/?,-:;} .' ASSESSORS MAP II: OIlNER: . 1: f-' f u.A' -Ie ''.6' " J-Io .,.... ~ '5' ADDRESS: CITY: 5',;tJ ,,1',- '5I+L , ."a TAX LOT II: PHONE #: 7 <tv- :2 r:'c e STATE: 19 A' E... ZIP: 7'7'-1')'/ BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCIIARGE) + $.45 (ADMIN. FEE) = $16.20 . . ~ CONTRACTOR: J.I....."'7:..< :l'1fA"-",,,,, /'O~ r ADDRESS: 2.s-u t:" J'7?f'rl.....~A' A',/ J." f PHONE 1I: CITY: 1/"';'/~-r-~ STATE: oRE CONSTRUCTION CONTRACTORS REGISTRATION 1I: 1/3?.2.... '73.s=-- J? / ,r ZIP:,<71'i/8-? EXPIRES: <'L' Jd-9j- BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOII PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS CORRECT. ~~ ~A'i'-URE I~-I'''-:l P DATI:: FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: Ib-I/"'- 17 JOB lI:q?D57 z::., RECEIPT II: :l71?'u ISSUED BY: ~ ~ TOTAL AMOUNT COLLECTED: 11 Iln,;).6 -------------------------------------------------------------------------------- ~J