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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 /od-f7r6 7? , zw,77V7/ 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 forth DATE OF APPLICATION:(7 q RBCEIPT I}:o\qL ISSUED BY:,/ TOTAL AMOUNT CoLLECTED /0. Z: JOB ^/ uJ {t:?N /3 ?/