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Permit Backflow Test 1998-11-16
v . SPICFIELD - BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIE::,D OR 97477 ~FFICE: 726-3759 INSPECTION LINE: 726-3769 -------- -.---- -------------------------------------------------- ----------- -.----- JOB LOCAT:i:ON: 9/0 Jj'v...../f ~td...C , ASSESSORS MAP 1I: / 70323 L/ .3 OVNER: 'FU.7i:i.tf-<- tf J-I"......-c..S ADDRESS: {I, 0.. AD 'f 1f{')... ~ CITY: E; UClIM , (j -S'/fi.~~, d TAX LOT #: Lf70 0 STATE: O~HONE 1I: 7L/Lf-.2~Co6 ZIP: 77l;() ( BACKFLOY I'ERMIT IS $15.00 + $,75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: )-Ju~l7<.-(' T,<'~'7;<2/,,~, ..!/ ~~...vLJ$c..~-<...... ADDRESS: ';;J.,S"";;;J.,;;U{ 'J/4_dA'A'v )4~,~ PHONE 1I: 9 .J'..r-- ,y:1./ 0 ZIP: 9?f"B-? CITY: v<:~",-~.__ . 't. ; ''-'I:; CONSTRilCT:,ON C01:TlY!qI;,9,~,~.I!-EGISTRATION 1I: ) /,1' $7 ;;} EXPra.IW~t-, ,!iL.,,~tt?7 AUTHORIZED ~~ALL EXPIRE IF THE WORK An;~~~~~~~'~~d'by the ciregons~~i\i~~h BY SIGNIN'; THIrsOPE~!'lITlA~l'L~t~TtO& PE.frIMF.~Ft,;fO GAll!' n~rIDl&2,;;Vg.,;i'f'IE01- BACKFLOY PREVENJ',I9,N I)EVICE~HASBI\~~~^~$tAi:L'iIDT iIN'tP. ~~oBQ)at\]N~ll~ utes by (726-3769). I I ALSO' STA1'Ef"'HAT ALt;'tffiiORIfAlrION df30 J'1UlM.li'lb\aItNm0~ lone ~.., ' Il' ,met} e' the te e CORRECT. calling the center.lNotuiility Notification , number for the,Oreg~;-332-2344). ~/ /. Center IS 1-8 ' _ n ,,( 7/-C.. IJ../.;-:?r 5 NATURE, DATE STATE: o/f: FOR OFFICE USE " ---------:-----------------r----------------------------------------------------- DATE OF I,PPLICATION: L 1 / J/O / q <( , , JOB II: l' ({ 0 71 L{ RECEIPT I: f) ~~~ . ISSUED BY: /{ 11/i1liA ~ ' TOTAL AM(IUNT ~OLLECTED:<t J I, J. 0 -------------------------------------------------------------------------------- " i