HomeMy WebLinkAboutPermit Backflow Test 1996-01-12SPFI'{GFIELD
BACKFLOL' PBEVENTION DEVICE PERHIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SATETY. DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
CITY OF OREGOA'
JOB LOCATION:J c /z '&-
ASSESSORS MAP *:
al
TAX LOT *:
OIJNER:I
ADDRESS:
CITY:
ADDRESS:/<PHONE *:.-od o
CITY:f ?*ttMeb STATE:o€^zrPz Q zz/'/ a.
-1,-,44t- /
BACKFLOIJ PERUIT IS $15.00 + $.75 (STATE SURCHARGE) + S.45 (ADHIN. FEE) = $16.20
,/2C0NTRACI0R: L->Ol
)-PHONE *:
S ?".-, r-&te /J STATE: O{,zrPt q717 7
CONSTRUCTION CONTRACTORS REGISTRATION f, :5El>-EXPIRES:^r'?/
By SIGNING THIS PERHIT/APPLICATIoN, I AGREB T0 CALL FoR AN INSPECTIoN oNCE TtlE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSo STATE THAT ALL TNFoRMATToN 0N THrS PERMTT/APPLTCATToN IS
CORRECT.
FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
ISSUED BY:
JOB {I:
r
DATE OF APPLICATION:
RECEIPT *: