HomeMy WebLinkAboutPermit Backflow Test 1996-5-8
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING ASAFETY-DIVISION
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225, FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ,&,33 S'e/~
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.' ASSESSORf; ;. 17 o?' ",;(7 I ts7J.
OYNER:' / ~ Lnr..!&
ADDRESS: &63 <Th fJ/~ 0T((/Le.,l
CITY: ~/2.J STATE:
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TAX LOT #:
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PHONE tt:
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ZIP:_97~
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BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: R-(4L~- tvL1-0- !fu~6,,~C) ~ IhJ.r~~ S~UI<=-e.
ADDRESS: Pr () '&k ?Gis-::t(b t/ / PHONE *:
CITY: Sf7r,;:'; Cr re~ STATE:. ,()rC-,7
CONSTRUCTION CONTRACTORS REGISTRATION #: CO 4 q 5 (/J /
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ZIP: 7'?Yd f
EXPIRES:
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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Sf9NATURE
6/g'/7U?
DATE
FOR OFFICE USE
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DATE OF APPLICATION: S - s:- - q &
RECEIPT tt: 02/ LfZ ~ I~SUED BY:
TOTAL AMOUNT COLLECTED~P. ~)
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