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Home My WebLink AboutPermit Backflow Test 2000-5-11 . -= BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION:_ ~-3'fl?--;/ ~b"'~ I ROd. 06:1. ( ~ kA;~>~ ADDRESS: -'3'2p-y 1314/~./ 2 j CITY:~/ho/c..:.- /?~/ STATE: '/'-- / -5-/. ASSESSORS MAP #: OWNER: ').-)AY-/, <; TAX LOT #: o +L( ()0 P~f'~{ 756 - y/r&J &/ ZIP: P~<Y?;?' CONTRACTOR: ;;)~/ -P -""')1 ':~. ., rWe;,:. , . : .'t, ':tOn, (STATE SURCHARGE)' + '$.45' (ADMIN. ).9(, "..,j-:..,. C ", ",-~ .' ql/'t" ,\ Ji" 1/ fl"hl.. . ". ~._ '.1/; ~":I fUft,?_..,. ,',,'t.' 'PHONE;. #: FEE) = $16.50 BACKFLOW PERMIT IS $15.00 + 1.05 ADDRESS: CITY: STATE: ZIP: CONSTRUCTION CONTRACTORS REGISTRATION #: EXPIRES: ^ BY SIGNING THIS PERMIT/APPLICATION, I AGREID~~CALL FOR AN INSPECTION ONCE THE BACKFLOW PREVENTION DEVICE HAS BEEN INS~~~eED~ANP IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION~ON, THIS PERMIT/APPLICATION IS CORRECT. . . "lU/HORIz, 1/ I SHAl.l. € COMM6 'l:D UND€ XPIRE If: ANy 180 ~CED OR IS AA //iIS PER::E 'NaRk ~l</ ~~- """"IDO ~!!~l cO FOR OFFICE USE -------------------------------------------------------------------------------- TOTAL AMOUNT COLLECTED: JOB #: OO~OOo~/-O( ~ ..... .....0"" :D:D "".....z I'T1I'T1 CI) C"":J.. ** C":J 0:3:.. :P ..:DO ---------------------------------------------------------------------------~--~-<~ 1-1("')*........0 rr1 :x: ....... 0 ::::O:I:q..~ 0 "ZO'~I-' oen. 00"- 01 I'T1 010 0' ....0..00....0 ISSUED BY: DATE OF APPLICATION: RECEIPT #: