HomeMy WebLinkAboutPermit Backflow Test 1998-11-04CITY OF
SPRINGFIELD
BACKFLOW PRBVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPBCTION LINE:
726-3759
726-3769
JOB LOCATION:/Zfl il/k B/t /
ASSESSORS MAP II:/7 0\z-( j 7 rAX LOr *: /O t O o
OUNER:
ADDRESS /L ?V ,tzlaha"&k,tr//r1 PHONE *:
CITY:STATE dr
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BACI(FLOU PERMIT IS 515.00 + $.75 (STATE SURCIIARGE) + $.45 (ADMIN. FEE) = 916.20
CONTRACTOR: I//a/Er Fb**er.a/h rs
ADDRESS , /12 t/f/
CITY: "v/d STATE: 2rr
CONSTRUCTION CONTRACTORS REGISTRATION *:6a 75-
BY SIGNING THIS dUOTOEPLICATIoN, I AGRBE To
DACKFLOV INSTALLED(726-3769). r
CORRECT.UNDER THIS PERMIT IS Ndp90.You may obtain copies ol the rules by
COMMENCED OR I$ ABANDONED FOR calling the center. (Note: the telephone
,qNY 180 nt r pFFton number for the Oregon Utility Notification
Center is 1
FOR OFFICE USB
PHONB #,72 6 '6 J Z.V
ZIP
EXPIRES '{'d
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DATE OF APPLICATION:(7 q
RBCEIPT I}:o\qL ISSUED BY:,/
TOTAL AMOUNT CoLLECTED /0. Z:
JOB
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