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Permit Backflow Test 1998-1-26
... .,-- , , , SPIUNGFIELO " . l \~ BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION .{' .:'~, . "'" , .... , 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 . ::::~::::;::;-::~~~~--~;;;~~~~~~---- OIINER: '%.Gys J-It1.-MES,4'o,; L, L, G. / 1 '7. . ADDRESS: ..:~<V &;i<:" . ~:~i[ u_s, PHONE #~.ttf2..: 5?3'7-\. CITY : .J.$1t4[~!, ~tA'J'E: ., ZIP: ;II' ''U '(.I ~~(, . "6'0 V~O V,z,O (~ . BACKFLOW PERMIT IS $15.00 + $.75 ~~TE9i.~~~ + $.45 (ADMIN, FEE) = $16.20 . . . // ~~ 15'-'9<9. ~O'..o ~~ .. . CONT~CTOR; 11 eV.:5 /J/) /W/5~<{ ~,z,O(). ~-94,A ~~ /0.& ' .~' '1S' ~L / ) ADDRESS: ;-- ;;? /.?~(!,( .~ ~-n, ~"f 11: ( -Y{)3 b?'-':;> - S1J..::::>) CITY: PC?,714.n/! STATE: ~~ ZIP: P?7..:2? ~ 'CONSTRUCTION CONTMCTORS REGISTMTION 11: qq /0<;- EXPIRES:" ft(J .-, ~ .:~ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). STATE THAT ALL INFORMATION. ON THISPERMIT/AP~LIC T~N r;; n r ~ CORRECT, 7 ,7 .' ~X t .' . . ,.....- .' . / /' '. ~/<~ .cif t/ -----------------------------------------------------------------------------~(;D DATE OF APPLICATION: I, a 1 \ ct8 ,I', JOB U: Ot 10 (Q]]) RECEIPT 11: A~5 ~L\: ", ISSUED BY: m[ffiJ . TOTAL AMOUNT COLLECTED: ,'~\ .0.0 ....-. . /~6hJ DA';Y , FOR OFFICE USE ~. . --------------------------------------------------------------------------------