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HomeMy WebLinkAboutPermit Backflow Test 1997-7-24 '. . .~~. SPRINGFIELD , .' . . '.: .~ \~~ \S ~O\ "~\c\:,, . . . c.,IlI ~ ~ .... . ~~ . "\,\\Sl-l\'Y"':",. .,\: ':." .~,,\'v0\..."-v . \ ,\\I-\()\'ll.tS) . ...;~ \~BACKFLOY PREVENTION DEVICE PERMIT APPLICATION r>.'v~r:::r.S)" . .O\), CITY OF SPRINGFIELD cO'</ll~~'2 . '.~ '.I\:.H BUILDING SAFETY DIVISION 225 F~~~' STREET OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: {qR8'l t=t)rS\./i-h I'~ .' ASSESSORS MAP #: 1 'X()2()2).~b~ tiOO TAX LOT #: OYNER: . 1 c\w %t 't- 4-<flM J2r.lIJ1ll.. ~ ~ U" ADDRESS: L,q~~J-nV5\/yJA;.~ (j PHONE II: -'7L/J-7J)7 CITY: ~))'\.VrrF;J.Q)/ STATE:. ()V ZIP: ~/7V7? BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =~ CONTRACTOR: ADDRESS: CITY: PHONE II: . J STATE: ZIP: CONSTRUCTION CONTRACTORS REGISTRATION II: EXPIRES: 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. SI~1 ..' "'j ~dV/ - ~ a'1 IiAT'B'-I- FOR OFFICE USE ------------------------7----;1~-:-------------------~------------------------ . DATE OF APPLICATION: 7 2 Lf..t1-r. .. .[OB II: q 1 /} 22- RECEIPT #: '()2(; r 1.1/ ISSUED BY: ;1::, th'~ . TOTAL AMOUNT COLLECTED: 5b I/f). )0 -------------------------------------------------------------------------------- ~