HomeMy WebLinkAboutPermit Backflow Test 2006-6-1
225 FIrTH STREET. SrRINGFIELD, OR 97477 . rl-l:(541)726.3753 . fAX: (;;41)726.3689
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~ Contractor Infol'mation
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~ Checked for Delinquencief
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CITY OF SPRrn-GFIELD, OREGON
City Job Numbe/ 1iYYl7J.T1}(o -000'8:'s
Job Locatior \ to \ A rLn I"V\ ~( ~ YX:\
Assessors Mf r \'103.;;l5 ';;r;;~10 lit d, C5b
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Tax Lot
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.ATTENTfON: OreMn I~... .__
lUllOW rule~ adopt-rJ b -'I""~" yuu 10
Notificatinn Cellter ~N ~2.'(; Q&q'~"c!j'ty
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Stat,/\SJC", .. uY zj1!.1l COP ;';),. h~~_,
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number for the nr~M~,~;}~le.telephone
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. enter IS 1-81)0- '3'" !l-. _\
BACKFLOW PERMIT IS $52.65 (includes Permit Fee, State Surcharge & Ai:hriiriistrative Fee)
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Construction Contractors Registration #
By signing this pennit/application, I agree to call for an inspection once the backflow prevention
. devise has been installed and is visible for inspection (726-3769). I also state that all infonnation on
this permit/application is correct.
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Datp
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For Office Use
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Date of Applicatio!0(
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Checked for Historical Statu.
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S~ Drive (r:)lBuilding FonnslBacldlow ~entionl-03.doc
225 Fifth. Street
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Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2006-00683
COM2006.00683
COM2006.00683
COM2006-00683
Payments:
Type of Payment
Check
Cash
Job/Journal Number
COM2006.00683
COM2006.00683
COM2006-00683
COM2006.00683
Payments:
Type of Payment
Check
Cash
cReceintl
.
RECEIPT #:
Description
Backtlow Device
Miscellaneous Plumbing
+ 8% State Surcharge
+ 10% Administrative Fee
Paid By
LANDMARK IRRIGATION
SERVICES
LANDMARK IRRIGATION
SERVICES
Description
Backtlow Device
Miscellaneous Plumbing
+ 8% State Surcharge
+ 10% Administrative Fee
Paid By
LANDMARK IRRIGATION
SERVICES
LANDMARK IRRIGATION
SERVICES
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8Y of Springfield Official Receipt
.velopment Services Department
Public Works Department
2200600000000000726
Date: 06/05/2006
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
njm
2105
In Person
njm
In Person
Payment Total:
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
njm 2 t 05 In Person
njm In Person
Payment Total:
Page 1 of 1
1:44:06PM
Amount Due
14,00
31.00
3.60
4,50
$53.10
Amount Paid
$52,65
$0.45
$53.10
Amount Due
14.00
31.00
3,60
4.50
$53.10
Amount Paid
$52,65
$0.45
$53.10
6/512006