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HomeMy WebLinkAboutPermit Plumbing 2002-7-25 ZZ5 FIITH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 ~ ~4 e) ~ .",:]4 !~ ~ ~~ .~ ,;::~ ,\~Jq f')'J4 Owner. fYJ ~! 1- V' ~\ ,:~..L 14 < . Address !~J City .o~ is ~~ ~ ~~ i Contractor Information ~ ~ ~.~4 ;>%> ~ ~~ ~ o eo 'Y'~j4 .~-~ = ~ >- ~ ~ ~\~~ ~ fd ~~ .,,'1r' '~~) ~ ~\ ~ :~::~r::.. ;;](, [<>:: ~,~1:~f;;'1'i17!':.x,_.r~ TR{~N'S4*: OJ:.OCI004.6 DATE" JJjL ~~5 2002 ANT i~tC0;;2 $ 5)',75 CHI~~,jGE :~ CASHIE[\: 001 City Job Number ()~ 00 K7'L/" 0/ , Job Location c;2 7 I 7 /l7 CL-{ a Assessors Mapl I 0 3 ;;) s" I ~ ~b/) i ,~/t'/l7' -h~/c!. (J~ Tax Lot~ & 70 0 / /?/)II// r - :17 /7 5; .~ /!/J I / -~ '- /h LV '0 /-?J~ LJ I Phone 7'17- 7~ 7' . - , r 7t(/7 (JtIL State Zip BACKFLOW PERMIT IS $51.75 (includes Permit Fee, State Surcharge & Administrative Fee) Contractor 5 uffTr _s~ ~ fyJ A-t-~ ~ / H:7Z LJ;;yz/.LJ<;""r ~ , Addrf'<:<: 9'32)/, ~ !?/OL/ 120 Phone 99%~ 20"'39 ~ ~ City~7/A.4I--(~/nuV &1 r-t/ State. ~...( Zip 97yc(g- AnENTION:Oregon law reqUires y6u. ~J - ! ~ CorntiinCittinrlE~~a\!f6t~~tB~QfEfPgRM~I~~I_ (p! 9'? Expires 2- 2- 9 (b 3 ~~s:t~~i,:,,<:>tinn r.Anter. Those :rules are s~1. - .. . 'n OAR 952-001-0010 through OAH 8b~-UU 1- NOTICE: ~Q90: You ~ay ob~ain co~ies of the rules by THIS P~RMIT SHAll E . By SI&!m~JM~~Jltut!.~~a~1@d~t~~~o callA'ij1TNDftl~U'~ffi~~ij&r\f/QR~tlOn d~vi1'FJ~~~t~ta~001~~l~ty~~fflffiP~RspecCOO1~EfWE6~R t~~g~fJi%1flMI;Ii1Sr11t&lnation on thIS penmt/appUeatfolT(l'Sl~ofi'gcf.344). ANY 180 DAY PERIOD. ONED FOR Signature d?tJvt;( ~tz--- Date 7 - 2-S;-~e;z.. &/ For Office Use Date of Application 7/:;;?~/ C)QOd-- )J ,;y---- Checked for Delinquencies .X-.. ~ Checked for Historical Status Shared Drive (T:)/Building Forms/Backflow Preventionl-02.doc