HomeMy WebLinkAboutPermit Backflow Test 1998-4-15
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SPRINGFIELD
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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 ()
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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'
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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.
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SIGNATURE
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ID\'Dl:; /
FOR OFFICE USE
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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 ()
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