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HomeMy WebLinkAboutPermit Miscellaneous 1998-12-3 . ", BACKFLOV PREVENTION DEVICE PERMIT APPLICATIO:I CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET WFICE: 726-3759 SPRINGFIE::.D OR 97477 INSPECTIC:l LINE: 726..3769 -------:---i\1'Oil"tJ€Y------------------...------------------------- ..----------- .,----- JOB LOCATIO~) P~~lrJIT7~1-J4~~{: .' ASSESSORSAUA~cr:'ZE~ UlJretB rYnbfMMfhs' N~r TAX LOT *. '6 {&O r.OMME~CEQQ~ISABANOO~DFOR OVNER: ....b\o\c,l~~.':-~-f_.~ "!ld'(\W} f'/ ~ l Y\ C . ATTENTION:Oreoon law reouires you to . . ... \... II follow rules adopted by the OrEl!)qJl.LJti1j!y ADDRESS: . 't::, 5 SMd. Y\ve.. ~ln.ifin""M r...n'''' fIlQ~nVi!ll'.~p. ~fi71rti '15 r in.QAB2~2:~ffi01 ~ thro~gh OA. R 952-o0~ - Q 7 UO! CITY:-...l2!:.ff~ 9~l.fti '~'~'~~T"~'lf~~1 I I ealling the center. (Note: the telephone BACKFLOV PERMIT IS $15.00 + $. 75 (STATEnl:lrn\lli\11~~".C).rEl90[\;UQlif,\(,I\!_QI~fi~f~ a $16.20 ~"~'Ceme(is 1-1lO(l~3':t.'2'M4). c;ONTRAp'rOl';: .5. L. r. . " .( 577 (,'l""~ ADDRESS: )..,Wll.blol]l'\. ~Olv1.e.w !u>;{('"J \,^- CITY: ;;;!viN\r< i.-1/ V' 6ffl'i1.J1!JJ PHONE #: .STATE: (JJl- 7L(<{- 7/../-r ZIP: 11 'f CONSTRUCTION CONTRACTORS REGISTRATION i: SXPIRES: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN:;?ECTION ONCE TilE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE "OR INSPECTION (77.6-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT. ,\PPLICATION IS CORRECT. ~~k , SIGNATuif. ~J1J I I~- '?; ~1 ~ VA':!:: FOR OFFICE USE ---------.-------------------7----7-------------------------.. ------------ ------ DATE OF /;PPLICATION: ) '}. s q l' cJ JO:l 6: 991J1l- RECEIPT t': (J 3 2- 2.. , '1. t iSSUED BY: l\ 'h/J. <A.---- TOTAL AMOUNT COLLECTED:":;; / (~ J-O --------..------ -----------------------":"---------------------- - --- -------- -- ------