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HomeMy WebLinkAboutPermit Backflow Test 2002-8-23 225 flITH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 ~ ...~ ~J Job Locatiop ~ ~ Assessors Ma:> II r--.. ~ ::;).. < ..~ " ~ 14 Owner (", ~'-:' - ~,,,,,,-~ ~ -+~o'-<C's: ~ < Address ~ City ..~ ~ ~ ~ Ii"'\\ " "l'~ ',_, ','0 ' ~~ r' "..' "'~L' -:l:d'2';: ~\, '0"00' U' r contractor nJ.prmatlon~ r.,., " toll ow rules ..u~t""-rh-;S( rules arc S(l\ ,0. , ~ I\\otijicatl~n cen~~~1 0 tn .:lugll O^F. 9S2-0L:_ ~-~ ir.€orithtct3'PO I , ,......::' .h~ rlltBr '.. ..~ 0090. :ou ,may oOl~\I/N~re: the je\e~,nonc ;;:::' Aaa~e'S'J tile cente ,\ _, ,,,,It,, ,lnlrilcaj,Cr ~ numbertormeu'<;;llVOO -:;~;'" \ ~~ '.' 'J:",,.,,.J ~ . C':ntq.,: '-~ Q Clt:' Construction Contractors Registration # ~ ..~ I~ ~ ~ ~ ~ ~ e> ~~4 Date of Application ~ Checked for Delinquencie- ~ 001 . rb . CITY OF SPRINGFIELD, OREGON TRANS#:01-0010397 DATE:AUG 23 2002 AMT RECO:2 $ 51,75 CHANGE: CASHIER:Oof City Job Number (J ~ On 3 $. '9 b / fu-l ~IJC4-~'--~ i.fg u.:)~-; ~(l., ...(.-F'CvJ, Tax Lnt O~I c-"'L. D.4.L~SB- - {~~>-.! :J?",-,- , 20'1'1- ~ a.rn. -k=.-. Phonp q~J.-, '4:S q 2.- ~a-.-.-a&T,G~. ( State~ Zip c.j -/411 BACKFLOW PERMIT IS $51.75 (includes Permit Fee, State Surcharge & Administrative Fee) NOTICE: THIS PERMIT SHALL EXPIRI= 11= TIJr:: "'~'11' II ~Or.RIZEOUNOER THIS PERMIT-,S'NOTI McNCED OR I&>A~~JDONFO FnD i 80 DAY PERIOD. -.. State Zip Expires By signing this permit/applica iOIl, I agree to call for an inspection once the backflow prevention devise has been install~-a t~;i1ble for inspection (726-3769). I also state that all information on this permit/application' is t01~ Signatune' ~<< DatI' OB2~02- . ------- For Office Use 2 /:J~J ;) 00 2- ~ Checked for Historical Status ( Shared Drive {T:)lBuilding FonnslBackflow Preveotionl-02.doc