HomeMy WebLinkAboutPermit Backflow Test 1999-8-13
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SPRINCFIELD
225 r:FTH ~TREE!
SPRINGFIELJ OR 97477
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" ASSESSORS :1AP #: '~2f1- _TAX'LOT #:
OIINER: ~f.W ~~ €.-R...O to
ADDRE3S: I J-3 ~ .s~.... f1 ; f'L.J
CITY: ~ N r-,QQl pj rf STATE: r->>.
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JOB VJCATIclN:
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BACKFLOY PSRMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45
CONTRACTOr.: ~ \.ru\(\S0:\\()? .J _ _
ADDRE\S; C\~\()t () \<. ~\)pr ~~_ PHONE #: L\qX--W~...
CITy:~ffiQf\ (~l.\-{ ~ . STAT;: t'kffity\ ZIP:~3'
CONS1RUCTJ:ON CONTRACTORS REGIS~TION #: \ Q\ q\.p ~ EXPIRES: Q:. :J..<i)' tf)
(tie", MJ ')
PHONE #: 71/'7 -J fU} Z -leAN/€- JemS~
ZIP: 97'{7 7
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(ADMIN. FEE) = ~ I G" Sa
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.
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FOR OFFICE USE
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RECE::PT jl: ~5f)!JJ.) ISSUE~ BY:. (:!J~
TOTA:' AMO:JNT COLLECTED: \\. 0 ~ .
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