HomeMy WebLinkAboutPermit Backflow Test 1994-08-12u.4.8.
SPRII{GF!ELO
BACKFLOV PREVENTION DEV]CE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-
t2
CITY OF OREGON
JOB LOCATION:
ASSESSORS MAP #:rAX Lor #: //m
OIINER:
ADDRESS:
CITY:
L
PHONE S:7y'?-azcz.ZIP z
V'tz 77
DATE
BACKFL0V PERMIT IS $15.00 + $.7S ISTATE SIIRCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHONE #:
CITY:STATE:ZIPz
coNSrRUCrIoN coNrRACroRS REGISTRATIoN #, //6/2 EXPIRES 2 // -2O:? 7
BY S]GNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). r ALSo STATE THAT ALL INFoRI,IATIoN 0N THIS PERMIT/APPLICATIoN rS
CORRECT.
FOR OFFICE USE
DATE OF APPLICAT]ON:
ISSUED BY:
z^TOTAL AMOUNT COLLECTED:
o/"
SVF;}- srArE:
*q-erE
,
RECEIPT #, / /- /
JOB #:4cfiz->