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HomeMy WebLinkAboutPermit Backflow Test 2008-5-7 (2) ,. ~l ~l Q) ..1~1 J~'J ~, I:)OJJ 0) .,)~1 " I~ ~\ ~l ~ <(~j . (j j ~J "E~: r-~ ~. ~ ..1 ~ f.!\, ' ~j ~ ~ ...~~ ;?,. ~ Ol ~l ~l Q) ...~~ J:""'J ~1 ~1 ~ ~ ~ ~l f.'!', ' ~j ~ Q) ~l ~j .~~~ 0) ~, I:)OJJ ~l ., . . CITY OF SPRINGFIELD, OREGON SPRINGl?'8ts.LD .-l^"^' /-.__/~ , I -. _.,-Qy' I '..... .1~.~ l _ _ , 225 FIITH STREET . SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 '7"00 006'17.- City Job Number c..c,^", ~ 0- Job Location I ~? J ~AfIt/'; a u.v~ 1703. ZS 2- Z ,. o ~ lfO a Assessors Ma:, Tax Lot Owner f2:-<-t.. J '" ne....:S<.. ~'SLv Addre<< (51<=:) ;2 G-l-v- h (j Dr, Phonp - City "SpflJ Statp OL Zip 97(+77 BACKFLOW PREVENTION DEVICE PERMIT FEE: $63.50 Contractor II/formation Contractor :x..~c. (S-('7 ~ {<,<-,,-J~c.~ ~ p, o. 8o~7"t4<;" d- :D....n'9"-~ S"c... Phonp 7<(ti-7(5':f c/- Zip P If'o ( Addresc Cit:. F"'-'>, v State Construction Contractors Registration # (2(70-' '8"1S"/ /ct" Expires By signing this permit/application, I agree to call for an inspection once the backtlow prevention device has been installed and is visible for inspection (726-3769). I also state that all information on this permit/application is correct. Signaturp CN.~ ~ V'\--? ~ Date~1 or:: For Office Use Date of Application 5-7- c,; V Checked for Historical Status v - Checked for Delinquencir< Shared Drive (T:)IBuilding Forms.lBackllow Prevention I.oS.doc 225 Fifth Street 0" " SprIngfield, Oregon 97477 541-726-3759 Phone Job/JournaJ Number COM2008-00642 COM2008-00642 COM2008-00642 COM2008-00642 COM2008-00642 Payments: Type of Payment CrcditCard cReceint I RECEIPT #: . 1)7~~ ~. C_f Springfield Official Receipt ~opment Services Department Public Works Department 2200800000000000609 Date: 05/07/2008 Description Backflow Device Minimum/Adjustment Plumbing + 5% Technology Fee + 12% State Surcharge + 10% Administrative Fee Paid By DARREN SCHELSKY Item Total: L'heck Number Authorization Received By Batch Number Number How Received djb 03562D In Person Payment Total: Page I of I 2:35:58PM Amount Due 16.00 34.00 2.50 6.00 5.00 $63,50 Amount Paid $63.50 $63,50 51712008