HomeMy WebLinkAboutPermit Backflow Test 2008-5-7 (2)
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CITY OF SPRINGFIELD, OREGON
SPRINGl?'8ts.LD
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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
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Assessors Ma:,
Tax Lot
Owner f2:-<-t.. J '" ne....:S<.. ~'SLv
Addre<< (51<=:) ;2 G-l-v- h (j Dr, Phonp
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City "SpflJ Statp OL Zip 97(+77
BACKFLOW PREVENTION DEVICE PERMIT FEE: $63.50
Contractor II/formation
Contractor
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Phonp 7<(ti-7(5':f
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State
Construction Contractors Registration #
(2(70-'
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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
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Date~1 or::
For Office Use
Date of Application
5-7- c,;
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Checked for Historical Status
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Checked for Delinquencir<
Shared Drive (T:)IBuilding Forms.lBackllow Prevention I.oS.doc
225 Fifth Street
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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 #:
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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