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HomeMy WebLinkAboutPermit Backflow Test 1998-1-27 . e: ,.f Ii BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION .(' 6:'~.. . ",. , .... , 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 ~::-:::~~:::~-----~~~~-~1(~~---~~~~l-~-~--~~---------- .' ASSESSORS MAP It: \~@\)Y\~- - ~~~ ~~T 1t:~)O ,.,'. OVNER: '%.6"//$ Ht:J,M,,?;'> L. L, C, / ADDRESS: ?:"o. &~ S?/~ <e..u_So PHONE {5~~ 6ff2> 5~7~. CITY: /).p /p b--' STATJt.'- ZIP: ~V~C .. BACKFLOV PERMIT IS $15.00 + $.75 (STATE~~I~~ + $.45 (ADMIN, FEE) ~ $16.20 '. . // ~ / I ~ C'04?'4t JyO~<.< ~l" <5'~ . . . CONT~. CTOR: 1'1 /~V.5 r/ /) .!1/iltJ<!., ~-1-", ~O/Il ~t/ . /0& . v(j{-o ''V, - ~~. (" ) ADDRliss: ~ .:J OC;-(!.,/ .~ 0",;-" 0-9,. ~-9,p U: ~OJ b 1-/' S7J~} .~u ~\~ ~ CITY: PC?/7 /4-1'1// STATE?70~~,o~.t) ~..(-. ZIP: ~7.,;2..?- ~ . ~~ "'?'I)- ~ /.. CONSTRUCTION CONTRACTORS REGISTRATION It: 1~ / OS q,~0/.) {s>iP~ES: 9',/~e . 0-9 O/' . BY SIGNING THIS 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/AP~.LIC T~ON jI,S n r ~ CORRECT., ~X t " ..' //- . '".fL/< ~ l/7> y .........-. OATrY~J FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: _ \ .:{ Y'\., C\ 9: RECEIPT It: !4 '7<..5"6""'5 - , - ISSUED DY: (~\,~I) vl '. JOB U:(\QT\U:a.h U,\ffi) . ~ ) TOTAL AMOUNT COLLECTED: .,. --------------------------------------------------------------------------------