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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 *: