HomeMy WebLinkAboutPermit Backflow Test 1996-09-24SPRTNGF!ELD
BACKFLOU PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
JoB LoCATION: X 1 \3 I4ILL ST
C'TY OF SPR OREGO'U
ASSESSORS MAP *zi 103 .35 3 >rAx Lor *z o/ 0 a
OI.INER
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ADDRESsI lqf U loY sT PHoNE *, 68G'l l30
CITY:,\STATE:OL ZTP z Q7rlot
BACKFLOI.I PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR:r ,r+
ADDRESS:
K PHONE #:
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CONSTRUCTION CONTRACTORS REGISTRATION *:O oo'?7 EXPIRES: t O*7 l-? b
BY SIGNING THIS PERMIT/APPLICATION, I AGRBB TO CALL FOR AN INSPECTION ONCE TTIE
BACKFLOV PRBVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFoRMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
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FOR OFFICE USE
TOTAL AI.IOUNT X)
JOB *:7bt LYBDATE OF APPLICATION:
RBCEIPT *: a o ISSUED BY:
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CITY:^ fi^aen e-