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HomeMy WebLinkAboutPermit Backflow Test 2000-9-12 I . .!\. SPRINGFIELD BACKFLOV 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: \ '2.c'7. VE.L KCl'::f. ot, .' ASSESSORS MAP l!: TAX LOT l!: OVNER: '6lZe 6 I;-t~-) ADDRESS: 12C, 2.. \}€:L- ~SE. CITY: 6(J~\N6 f:\IZLQ flJOT/Cj::. PHONE l!: S~~~~E~~SHAI/ .-,,~ ZIP: i:n4-17 "V I HUI1ILEO UNO ~.,.,. '''1:: IFTHE~ COMMENrr=,., . ERTHISPFP," '_ aRk BACKFLOII PERMIT IS $15.00 + 1. 05 (STATEI\SURCHARGE-)A+'? ,$:,'{+54/(ADMIN!ITFEE')) = $16.50 '., lOUUAYPEAIOO - 'iJUNEOFOA . , . CONTRACTOR: VI N.Th6.r. lAN.\)S(Mlf G l>E.S>\bN. LLC ADDRESS: v. a - Gu.,L \~ ~v'3 PHONE l!: ~ I. - \SS'\ CITY:~ ~~~ STA!,E: Or;2. ZIP: ~744a 'allow V'\ v ,,~, _ I CONSTRUCTION CONTRACTORS REGISTRATION lI;!ifj..~...J~e~lidn~d" "4u~IMS: ~ 0 I ~-~;v"lie t - -YU1eu Y UI, . ;0 OAR 952-001~0~ Those rUle;~gon Utilit) BY SIGNING THIS PERMIT/APPLICATION, I !ILlD0as:~' 1~6Rr~h~.. 6wtONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN IN 'mme~ srv4sIt~L!lf ~CTION (726-3769). I ALSO STATE THAT ALL INF ~hW6t ~l1!Eaffiritf. ~MJ:.ucI.:'rION IS CORRECT. . Center is 1.6g8 on Utility NotJ. o~e . nn-~32_2344)."'cat,0,., j){fiIZ~(t' ~96tZ... ... ~a,,1.{/ sIGNkruM \ Cl ... \ Z. - v::) DATE FOR OFFICE USE ------------------------~-j---------------------------------------------------~- DATE OF APPLICATION: ~/ Fd/09 JOB l!: (}O~OI3 f:f 3-01 RECEIPT #: ISSUED BY: 5E -I , -to::::r:J DD TOTAL AMOUNT COLLECTED: (") A;: rM 55 :X:C':J.. ** C":IDCcn.. . , ::r:>Z.. me ______________________________________________________----------------------~~_o~ ::I: fTI I ,.......M...-..O 1'T1~ f'-..JO ::ONO ooGJONGJ a. . Of'..) 0101000 ....010000