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HomeMy WebLinkAboutPermit Backflow Test 1994-10-10 r -. .0 BACKFLOY 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: _'1' 0 0 F ~AllrLA4 S' ,(1/"0 ,'-.-.dI, luJ;...,I tZ (~-- . ASS~SSORS MAP I: /?"/J ~ "$ 4 2-2- TAX LOT I: O;;)<fii!,."$-s! O~ER;~~.hI f- f LVU"/_r? ~ / 5A--//E5--,r::=-~.) A'~A"'r r ' ,.. ~- " . J / ADDRESS: JO 0 &.~ "ff~ PHONE I: cO 'f'f- 'I b / l/ CITY: SD~p-,J (J STATE: (')IT ZIP: 97'177 BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: e yYj 0/1 A J",/ ;;/ ~AU'~ ADDRESS: -.:L'-I fr r;- I M a A~ R,.,/ PHONE I: CITY: e..IA......I /YI j STATE: (() 11 CONSTRUCTIO~ CONTRACTORS REGISTRATION I: (,.,:J. ~ / 1'17- S <?yt, ZIP:.JL'f 0 ~ EXPIRES: \('-? /- 'I') BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. , (l j ~ . /l-y'l ~E (] '7./i..(l~ () rr --1.!! - /0- 1</ DATE FOR OFFICE USE DATE OF APPLICATION: /t?//~~?~ JOB I: 9110470 RECEIPT I: IS/)/2 ISSUED BY: .('.?IXt, TOTAL AMOUNT COLLECTED: / t:? ~