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HomeMy WebLinkAboutPermit Backflow Test 2003-10-9 . q 0) .~ ~ ro u .~ ~ ~ ~. ~ ~ .~ C) ~ Q)~ u .~ ;>- cu. Q: q' OJ .~. ~: ~: 0,:),: ~, Q) $;-(, ~. ~ 0) ~i ~. u; dl f/V(\, ~, ..." . . ~,~: "~. ',- CITYIOF SPRINGF-IEI5D, OREGCDl'{' . 225 firm ~TRI:t:T . SrRINGnELD, OR 97477 . 1'11:(54 ])726-3753 . FAX: (54 ])726-:~689 , ' ,. . . City Job Number COvz4 ZO 0 3 - 0 I 00 J Job Location \RS~ i703. 25'3 I f\ 1'-1 rV\ P \ c- , Assessors Mal' Tax Lot nZ7cTCJ Owner -~\.)~..,.....,..., ~~l \ \)l9t'" ( Phonp Addres< 2-L\ ~ \ 811 \,J~~ Zip 9'/%'Z- \ ^-' ' State_f \)(l City BACKFLOW PERMIT IS $52.65 (includes Permit Fee, State Surcharge & Adminish'ative Fee) Contractor IlIformation ~ \ \_1_ I c........ n<'l'-1 qUlleS yOU to Contractor '1--'-""'--1' <,'" - ~.r,~n11\ laW re L";""l ATT!:N IIV"'-' - - b tha urtlyuoo ".--.1 (,1 (Iules adopted ~ u.I! sale seU,or\ /' t I \II D (2.,,)\/1 J~ ~___'or ThOse r ~hYi9A~\ n""f'Ar-'~ ~ l.(Lr;). 7' 'lotitlca\lu" ~QO-;~001 0. thlOUgl '~- rules I ~ - (t%. ".,()AR 952- ,"".....aies 01 \"e C).r') l/ 1 City " -4 OLA "-~ ,,/<1 ~~u,' ,\,~ ::-t&tafetal~~.;:; ~-r'o~.ll"~e /' ( 1-; ailing l,\'1e center, ~ /-ltility Notlllcatlon c ,/,0 Construction Contractors Registration # ,,~~~h"r I~ t69$1ia;,M-t:r:'-?M4~Xpires 1''/.r. ",I{ ,..,_...+orl~ -_ Addres~ By signing this permit/application, I agree to calI for an inspection once the backflow prevention devise has been instalIed and is visible for inspection (726-3769), I also state that alI iofonnation on this permit/application is correct. ~ /' 'i'la~'f. / ._____ . \t '\\\t. ;. ~a\ ,~,/ .' 7 '-..; .' _c."'?~~t?~~V~~'--07 , / " <./ - \\ 5~ ,i\\';) a~t.'V \' -- ,-""'\ \\~\)I:- :ol\~'V " ",LcD "u \s ~ For Office ~l]i.\\(s~~;-~ ~t.~\\)\l. vp-~'{ W" - Signatur(' Date of Application /6--6 7' - 0 "'3 Checked for Delinquencie< ~ Checked for Historical Statu~ ~ Shared Drive (T:)'Building F'ormslBackflow Prevcntionl-03.doc