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HomeMy WebLinkAboutPermit Backflow Test 1998-4-15 . .. SPRINGFIELD ~. ~ i\-lE 'NOP-\<. 'to\01\CE: S\-Ifo.ll E~PIP-E II" RWlli IS ~Oi PEP-Wlli i\-llS pE: BACKFLOII PREVENTION DEVICE PERMIT APPLfCtl~I01'i\'Z.EO \l~OEP- l'lOO~EO rOP- CITY (.:' SPRINGFIELD fo.\li\-lOt\ P- IS fo.er>i BUILDING SAFETY DIVISION Ot/lWlE~CEO 0 00 C ~ pEP-I . 225 FIFTH STREET ,,~'{ ~E: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 JOB LOCATION: 2-oQo 6 L.1.f1f-1, ere...- 17037-<:;] I () $, ASSESSORS ~:AP #: OIlNER: ~c::.lc::'A'-l (^-lV!ES-r/M..G,"rc5:. ADDRESS: 2-3s-0 OA-lc..JkO^" IA//'r.,.- PHONE #: CITY: GUWAJ't7 STATE: o,e'E TAX LOT #: 77()O lfgs- '+7// ZIP: 91'+01 BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20' CONTRACTOR: T tA./ I ^' It!. r u 6 ~5J ff?f..-.LUv1!3> IN. - ADDRESS: /S2.S" (P-VIA..l~ PHONE #: '=>8Y~ (t.f4.c...f CITY: E<<rYEN'E STATE: ot<:.E CONSTRUCTION CONTRACTORS REGISTRATION #: 1'7~9~ ZIP: '1' 7<.fe> <-I- El{PIRES: (,/9 g' I BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE TIlAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS CORRECT. ~L3k.._'. SIGNATURE ~/(s-/rK ID\'Dl:; / FOR OFFICE USE ---------------------------t---7------------------------------------------------ DATE OF APPLICATION: L/ / /5. q i JOB #:!L..'XOC/-SCf RECEIPT #: O::E!Lfl{ L/ . ISSUED BY: '"/..... rn 1M....--. '" ,- TOTAL AMOUNT COLLECTED: Sfl fJ ' J () ------------------------------~-------------------------------------------------