HomeMy WebLinkAboutPermit Backflow Test 1998-7-15
"
.
.
\
SPRINGFIELD
,.,
r1r\'C.'t-l i'i
\('.~'. 'C.'/..<(\I\'C. \ ~I \s \,\0
BACKFLOlJ PREVENTI~(blt11.C;;~~I:~ J;~~'C'i~~i'\:OI\
CITY OF",,\St(1\.b~"F~I;:MU'C.?- OO\,\'C
BUILDING ISAFE(51A\1lRrl'srq!!, r>-er>-~
p,'S'i'r\ fi) 0\-'1
225 FIFTH STREE'r "^~~'C~\C - ~~~\O\l, OFFICE: 726-3759
SPRINGFIELD OR 97477 CO .1 \?() i)llo.i - INSPECTION LINE: 726-3769
-----.-------------------------------7--t~~-~------______________________________
JOB LOCATION: 353 J DO U 6-UtS D j2 Hie
. ASSESSORS :-lAP #: J 'lO). D0 /1-
OlJNER: ELL I C.6 LEI C Ii ~
ADDRESS: 3 ~'?:> i J0Du6-t/1:S 'bRIIIE
CITY: So Prt tJ6-FtFU) STATE:
TAX LOT #: ()()() 0
M'Ie: \)'t,) ,;';',-,77"7
PHONE #: DAi: (<;,-+/) 7:1..1. -,;l~3
DR-
ZIP: 'f'7'f7t
BACKFLOlJ PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:
PHONE #:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOlJ PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE fui{ :;~~r..CTION
(726-3769). I 'ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
"--f" /' '" ..
r d ArLc.A' '
SIGNATURE
);r:c-4
7/{~/9 6
DATE
FOR OFFICE USE
--------------------------~~-~7------------------------------------------------
DATE OF APPLICATION: 11/.91 ( ..... JOB #: q ex 08' ]<)
RECEIPT n:_(}~()7-1-(/ ISSUED BY:. 0f .1t11J/'...J -
TOTAL AMOUNT COLLECTED:' 1. I&;. 2-D -
--------------------------------------------------------------------------------