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HomeMy WebLinkAboutPermit Plumbing 1998-1-28 --= tlti ,t' \? BACKFLO~ PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION .'f> , ,:~ ,>I~ \ 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 ~::-::::::::~-----l\\tf\~~\i[.C\---~V\t\\c;--~~-----~------ " ASSESSORS MAP It: \ ~a~C)<o~~ - ~ TAX LOT 11: 1)~"l.(iJ " ,,', O~NER: ';f';(5YS Ht:J,ME> L, L, C~, / ADDRESS: ?Ao. g,,c . ~.-, -e.. ""-"'- PHONE {5QjJ blf2>5i3'2\ . CITY: p.p /0 ~ STA'Pfto ZIP : ~8 I>C'~ BACKFLOW PERMIT IS $15.00 + $. 75 (STATJf'~~~~~) + $'.45 (ADMIN. FEE) == $16.20 . DOlt;; Vt9~ v;- & ' . ' // ~/./<:: / J :1~ ~(:'~ (.('0 ~( CONACTOR: ' /1 /:: r ~ r-/ () /VI e~ V~ VAC (€r, ADDRE'fsft'" d //~U "> - O-'?;-.:_Ot9;(l ~t9~~Jt: (~t?3 ) b ?,-/' ~-::::>} \~ - '"1& \9 ..0. ~' , CITY: Po, 7 /4-n/! STATE: V~~~-'91$>.~~ZIP: '77.,;2,?. S CONSTRUCTION CONTRACTORS REGISTRATION n: c;?f / 0,5 ~O,('~\S'~J~ims:, 9,hfJ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO~ PREVENTION DEVICE lIAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION g~~~~ ~9) . STATE _:IIAT ALL IN~RMATION.?ON TIIIS PERMIT / AP~ ~T~ fti f ~ /~6ha' DA7 / FOR OFFICE USE -----------------------------------_.~------------------------------------------- DATE OF APPLICATION: \ - .!i..f\.a.~ .11 ~ \ Jon tl: c\. <?J)\D5 RECEIPT n: ~ '65<61 ," ISSUED BY: '(] \U...A.^-J TOTAL AMOUNT COLLECTED:' (~\.~') v --------------------------------------------------------------------------------