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HomeMy WebLinkAboutPermit Backflow Test 2007-9-7 (2) 225 FlITH STREET . SPRINGFIELD, OR 97477'. PH:(541)726-3753 . fA-X: (541)726-3689 ~l ~j ~ .~~~ 1;....,'.> dd' , !l ~) Assessors M'p .#~i ,,---II ~.I1 Owner ~ <Ie: ( Address , l,_~ ."~i ~l ~ ~ f:!I\ '. ~l ~ ~ ."'~( > ~ Q\ ~ Q; .J.~t ~, ~i e...( ~ ;;?:- ~ ~j r,"I, . ~; ~ ~ e) ~._:l ., ,-j .5f11 u) ct$' , !J gQ! . . SPRINGFIELD' 1 n I I : -0(\...-------.//'----. . I ----=::::.-.------ ~ I ~,,_ ~~ CITY OF SPRINGFIELD, OREGON City Job Numbef{yY1 ?fIlYl - 0/3 f.t?~ JobLocalion~oq 5. o.PkiOrlnrf Dt2-:,,..JL <\,1)1' 1"1 (,' \. (,f J . Tax Lot 01<. U11L.{1'~ J;. i I.. I" VV\ Il '^~_ ~_r City '<. "'10 q s, i<el U},onJ . ~V--';- <;:.nr.,/\~+:P r.e Stat.. ({) (JQ. zip...Q7<-1. '1 R ~IP- Phonp BACKFLOW PREVENTION DEVICE PERMIT FEE: $61.50 Contractor Information Contractor PI) (J (q..{2i"\<<:' .I://Ir - . , Address '"JQ..&g5 5,!).), f::-"'1S/'Ild:'1 /!()(u:( Phone_I-Co~-&fI::J-"Ci74:> City I,Oi'l~oY\ul'''P_ State (r'JK Zip 070'10 Construction Contractors Registration # q, (l ...., Cl "- I Expires By signing this pennit/appIication, I agree to call for an inspection once the backflow prevention device has been installed and is visible for inspection (726-3769). I also slate that all information on lhis permit/application is correct. Signaturp --d..] r? (412 7 Date OCV07!O(/, , , For Office Use Date of Application 9~7./07 ~ Checked for Historical Slatus ---- Checked for DeIinquencip< Shared Drive (T:)/Building FonnstBackflow Prevention '.07.doc