HomeMy WebLinkAboutPermit Backflow Test 1994-12-28SPBINGFIELE,
BACKFLOI{ PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
CITY OF SPR'A'GFIELD, OREGO'V
JOB LOCATION:a
ASSESSORS MAP #:
oTJNER: f/tr ) f C*," /
AX LOT *:
ADDRESS:
CITY:
-dli 7t l ,2, t.*, ,,?o/PHoNE #: 7q€- d 78 7
STATE:<?E-ZI?z
BACKFLO\^I PERMIT IS $15.00 + $.ZS ISTATE SURCHARGE) + $.45 (ADMIN. FEE) = $16-20
CONTRACTOR:
ADDRESS:
CITY:
PHONE *:
SrArE: O Q.ZIPz
CONSTRUCTION CoNTRACTORS REGISTRATION #t l,;,,/'7C EXPIRES:<s,i,/g I
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--BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLO\tI PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). r ALSo STATE TrrAT ALL TNFoRMATToN 0N TIIrS PERMTT/APPLICATIoN rS
CORRECT.
FOR OFFICE USE
q7q 7*
DArE oF APPLICATI)N' /Z-28 '27
RECETPT +: l+a57 rssuED BY:
TOTAL AHOUNT COLLECTED:2a
JOB #:?{ =-
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