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Home My WebLink AboutPermit Backflow Test 2002-8-26 ZZ5 fIrrH STREET. SFRlNGFlELD, OR 97477 . FH:(54 1)7Z6-:~75g . FAX: (541)726-3689 =: ~ .,,~ ~. Job Locatio!' ~ ~ Assessors Mar .,,~ "~11 Owner ~ JL..tIJ/tJrt.o ~ ~ City ez.-.?O,e. -~ .~ Contractor Information ~ ~ .,,~ ~ n Cit:' j)}~a. ce, r = ~ "'~4 ~ i ~ ~ ~ ~ r_~ Date of Application ..~ CIi""'''' fu"JoIi"q"~ci~ M ~ , . "' . . CITY OF SPRINGFIELD, OREGON TRANS#:Ol-0010413 DATE:AUG 26 2002 AMT RECD:2 $ 51.75 CHANGE: CASHIER: 061 City Job Numbr' 07- -cD? 80 - 0/ 26,,), I<tV'f'( /7032.J4 '1 f.NiJl..L . ~o>F ^, cAe q7L1/7 / /L(O C Tax Lot U> -"'l. 'i0~*-~ ,,-13. I ..$ _,~ Phon" ~;~~ ~~q,~~<<Y (..~ ...,c" ,,<cs ~ "-",;;s.v BACKFLOW PERMIT IS;SS1.75~lu~~~Fee, State Surcharge & Administrative Fee) L----:~..# ':,~~~'i0~' ~\~~-&> ~"\~ . ~ A....~\~\;S..e'3 ~~ J VV\ . ~~. 'b~ Contractor Ct'1 qr rc;rq,<;.):~" '?-' Addref~ '2538'7 "? X.6v1C€-~rse- ff-t l \ Stat" OIL Addr".. Jqs'O ~A;..s"1z,..~ Zir 9 7 ~C// Y'Sy~ fJI...13 - Zip c;71..( f) ~. .\ :\0 ,~~.....~ 0 / ....0'" _~E~pi~es:-', '6' I g j::) :J / _~ ...0..- ^co .n~ ,aV' I ~ *'- 0' ~. '<jJ ~>o- 0 ,'If ~0 ~0'" -f?' 0<:' 0'::'. o~ . 0~,\~..."0>lS'~~ By signing this permit/application, I agree to call for an insp~cti6>ri~6%cel'he.liacR'fl6{v prevention ..'J . ~........, ~" ..v- .~... 0'" ,f)'" devise has been installed and is visible for inspection (ilJ6-3769). J,ralso~state tlfa!~ll-information on this permit/application is correct.-!:- '~0",'I>~0<!1-0~<;;:,\~~ ~~~0~~'''''~~ ~ ,v ..." ~() !:l" (p :<.~ o~ <:'Jro'l/ . I '~o~c,~~'-;)rv<:S",~ 0<!1-00...0~,<:P~ . " '~~ -J;;, " C; 0 " Signatur ~ ,o~ _$'...\.o ~0.>IS':~ Datp ~ / J-t/ t/7.... ...'~ P:J<;;:" ~~....:<.'\J' ~>O' ::>\5 c,'If :00 CJ~ ^\:;~ For Office Use Phon" Construction Contractors Registration # {;,r3b3 D152b02 c.--- Checked for Historical Status ( ---- ShamI Drive (f:}lBuiIding Fonns/Bac:kflow Prrvcntionl~2.doc