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Permit Backflow Test 1999-8-11
.. ~'R'''GFIELD , BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICA'GON CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 ------- ----------1777---------------'"------- ------------.. --- .. --- ------------ ---,- JOB LOCATION: ~J f!?......,A ~,. L LNn:!St. ' " ' AIIf8~!>,~QIl.$.tI1AP",U~ Ik~I-,{},}J;I~ ,J- 'l '-1 j () THIS PERM'"I'c;!lJA.rL LOT n:;;)-()())-... follow rules adopted by t Oreggp,Utllllv ~ ,JUTHOFl/ZEDU EXP/FlEIFTHEWOFlK Notifi"q.y!\l,J;,RJ nl, ".. "JJIJ~ ,<<~ iDiO, S f -<-77< ,.. ~ ,.. NDE8 THIS Prnjv'1 ' in OAR q~?-OOl-001 Q1.bro)Jgh <>>,R 952-001.. IVlA:D OFlJ$..ARANOQ , I/::i NOT 0090Alt1tIW,~~:,~n,,,;hy."'i".~~,,(,IGK",^(,,,' C. ANY1800AYP-Enttrl-/F; :i, N~f(q)1J- /(' ~ ~ , Calm'he ce.D~' ote: t~ tele!Jl1one , ,~. , Y: .h,,)', f....,q~.<iI~,,'iM STATE: (0-",>- ZIP: 979?'J nurn eTlor '"=~<''' " .. , Centp' i~ 1.ilnn.::l~","'l44). BACKFLOV PERMIT IS $15.00 + \.OS (STATE SURCHARGE) +$,45 (fdJMIN. FEE) CONTRACTOR:---.L!...,..i7<../l~~,;~/;.../ ~ J4~~,1'o:~~~,<, ADDRESS: ,Q,rJ..2 t: ~rl...~ AeA'/fv I.,. PHONE -Ii: '7.fir~3:J./Ir- , CITY: I/.,..-.c_ "7/lJ-. STATE: 1'9~ ZIP: ?7YY7 _,,_EXPIRES: <1-'3d~/t10 , , CONSTRUCTION CONTRACTORS REGISTRATION 11: I / ,"{ ::- 2.. .. "", BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLO\l PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBU: FOR INSPECTION (726-3769), I ALSO STATE TIIAT ALL ~NFORMATION ON TIIIS PER:,\) 'l'/APPLICATION IS CORRECT. "v?~ "n 'r-//- j f' DATE ,. POR OFFICE USE ----------------- ------....--------------------------------. - - -.- ------- ------- ------ , ; , DATE OF APPLICATION: ,K=-I/ ~ 79 RECEIPT tI:n~'S'/7 Y ISSUED BY: /I. TOTAL AMOUNT COI.LECTEO":Jt If;, 6'0 '. .JOB U: IrJfY(I/7&1 0 qCll () ~ (" --------------- --------------....------------------------ --.. - -. ----- ------- --------