HomeMy WebLinkAboutPermit Backflow Test 2001-04-09CITY OF SPR OPEGO'U
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BACKFLOU PREVEMION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SATBTY DIVISION
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225 FIFTH STREET
SPRINGPIELD OR 97477
OFFICE:
INSPECTION LIM:
726-3759
726-3769
JOB LOCATION:0
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BACKFLOW PERMTT IS $15.00 +1.05 (STATE SURCHARGE) + $.45 (ADuIN. FEE) =$16.50
COMRACIOR:
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CONTRACTORS REGISTRATION *: /.1 I 7 a 3 EXPIRES: /'2 2 o L
BY STGNTNG THrS PERMTT/APPLTCATTON, I AGREE TO CALL FOR AN TNSPECTTON ONCE THEBACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AI{D IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLTCATION ISCORRECT.
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FOR OFFTCE USE
DATE OF APPLICATION: CZ+- C1- C I
RECEfPT #: q szE JOB *oa_grc)l - o t
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TOTAL AHOBIT COLLECTED, \ [+, 5?)
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