HomeMy WebLinkAboutPermit Backflow Test 2006-10-23 (2)
225 flrrH STREET. SPRINGfIELD, OR 97477 . PH:(541)72G".3753 . rAX: (541)72G-3689
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City Job Number (l)p - 0 15(p ~
Job Location '~d-d-O eO, I p 'j\....v'" 0 (>,J
Assessors Ma:, J '7 f) 3 do do.. / J / RL/ rsu
Tax Lot
Owner /!IJ PI (' t Cl/tS; L.Jh t;j ('\
Address 3J-J-o ?-o,(ti~LwoorJ
<Spa!..naNd
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Phonp
Statp ~.0dJl../ Zip
CJ'7y7Y
BACKFLOW PREVENTION DEVICE PERMIT FEE: $55.35
Contractor Do (" ke. ( l.-Vl nrJs CoJU ~
Addres< Pr<. B 0'1-.. <:67
City 4- { U PI. dON
I rvle "l+(<J)'''' Ttllc
Phon I" ~r..;I-fagg;-7901
Zip C;7Cfo 1
Expires 9- '3{) -07
Construction Contractors Registration #
State (!) R
4301?
By signing this permit/application, I agree to call for an inspection once the backflow prevention device
has been installed and is visible for inspection (726-3769). I also state that all information on "this
permit/application is correct.
Signatur~ ~ ~
DatI" IO~J-5~O (...,
For Office Use
Date of Application
J6/d.3JZtTo~
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Checked for Historical Statu<
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Checked for Delinquencip<
Shared Drive (T: )/Building FomlSlBacknow Prcvenlion8-06.doc
i2~ Fiftb ~treet
Springfield, Oregon 97477
541-726-3759 Pbone
Job/Journal Number
COM2006-0 1363
COM2006-0 1363
COM2006-0 1363
COM2006-0 1363
COM2006-0 1363
Payments:
Type of Payment
CreditCard
cReceintl
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Wit.
C.,f Springfield Official Receipt
~opment Services Department
Public Works Department
RECEIPT #:
2200600000000001479
Date: 10/23/2006
Description
Backflow Device
Miscellaneous Plumbing
+ 5% Technology Fee
+ 8% State Surcharge
+ 10% Administrative Fee
Paid By
DECKERS
Item Total:
l:heck Number Authorization
Received By Batch Number Number How Received
Ikw 020974 In Person
Payment Total:
Page I of I
10:44:5IAM
Amount Due
14.00
31.00
2.25
3.60
4.50
$55.35
Amount Paid
$55.35
$55.35
10123/2006