Loading...
HomeMy WebLinkAboutPermit Backflow Test 1998-1-27 v . '. SP'IUNGFIELO II ~f i:o BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION d 'f' 6:'~: . /10 ,,,..,, , 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 :::-::::::::~----~~~q~~~i\--~(i~~-~-~m______---- " ASSESSORS MAP U: \ ~()f),,\)l 0\\ \j TAX LOT U: O~ ..' - OIINER: '!f/i'YS HcJ/f'7E> L. L, G. / ADDRESS: --;T::o. 4;j.e" '~........-z ..d:'O}.R -":. PHONE lt/,C)oi'\6If2> 5~2 \ . /. '~ '.Ie \. - ~ ' ~ ' CITY: 1)-17 ttJ_ ~ !fm~' ZIP: "Q -b ''9-% ' -11-, ~~ ~~ Vl'& ' BACKFLOI/ PERMIT IS $15,00 + $, 75 (S'JA~~~I~) + $',45 (ADMIN. FEE) = $16,20 170 ~ ~o (~~ " ' , /./ / I <<II- 0'9 ~'9 ..,..~ CONTR,{\CTOR: 1'1 .i?vs /71") /W15~~,o~..., ~;_ ~~,. , , r::O& ' "u '00 1,,0 "~ ( ) , ADDRESS:;-r 2/?~c.?"> e? ~~J::~J.~v"'%-(r 503 b?'-';;?- s-g..:::::>} CITY: PO/7/4.n./l STATE: gif{~II/- ~r ZIP: '77..:2.'?' S- q ~ vI' ~ ~ CONSTRUCTION CONTRACTORS REGISTRATION U: "q /0., EXPIRES:, 9'/ Y' f! >, . .:~ . BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOV PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726~3769), STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPL:_C~Tf:IlN i"I' n r ~ CORRECT. ?' ,) , jlX1tt 't1. ~x t //' ' - OAr~~.7 ::~:-::-:::~:::~:::~---_-T~A~-~D\'~------:-~--:-------:::-:~ili()((A~ RECEIPT U: A~,' ISSUED BY: -cr,lfnJ TOTAL AMOUNT COLLECTED: < ~ I . ~D - FOR OFl'ICE USE ":" --------------------------------------------------------------------------------