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Permit Backflow Test 1998-1-27
. '.' i if BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION .' ." 6;'S::' . ",. ."". , 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 :::-::::~:::~---~~~~-~~~CJl---~~------i~~----------- .. '''''"0'' "^' ", \ <1-NI N 0 \ \ ~ "" .' n~\('{) . OYNER: '%~ys J-iJ,ME.s L. L, G. ,'. ADDRESS: ~v. &;ic" S?/-t -e.,*,,~":. PHONE Uf,S'6i161f2> 5?)2 \ . /. ~ -/J ~ - - . ~ p.p IP ~ ...,.s.T~~: ~1'- ZIP: Cl ~ <-13 . ~. O~ V~ ~". BACKFLOY PERMIT IS $15.00 + $.75 (S'P'A1Jf;'~~~ + $.45 (ADMIN. FEE) = $16.20 . 0'00 V<<o ~ ~( . . . /./ ~ / I '1)- Q ~~ ~ CON'ACTOR:' 11 /.::: V5> r/ ,) /W /5 ~ ,.o~ ~/n JS> ^ ~ ADDREfs~~ :j /?SC)> ' ~OO- -1~~ ~tNfs.~I: r ~t?3 ) b f./ - m~ ) CITY: Pc, 7 /4-n/J STATE: L'~~J\ ~~ ZIP: '77.,;2../. S- CONSTRUCTION CONTRACTORS REGISTRATION U: q q / 0 S'~-9 1tl".' EXPIRES: 9 # B' . ,- ^. .-:;. CITY: BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOY PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). STATE TIIAT ALL INFORMATION, ON TillS PERMIT/APP,LL.II.CCr Tt)ON ~nr~ CORRECT. 7'''. ~ <tC( ~X t /'---- /0'~' . .....-:...... . .--<?4'7 / 0/' !/ ....-. /~6h~ DA7 -, FOR OFFICE USE TOTAL AMOUNT COLLECTED: ISSUED BY: <~ t. ~n -----------~-------------------------------------------------------------------