HomeMy WebLinkAboutPermit Backflow Test 1997-08-25SPRI'{GF!ELO
CITY OF SPR"UGFIELD, OREGO'V
}fi*}Iegg56;6g**.**APP
,,,f;l,lffi;;tt*oo - BUTLDTNG SAFETY Drvrsr,N
LICATION
OFFICE:
INSPECTION LINE:
225
SPRINGFIELD OR 97477
726-3759
726-3769
oN: _fl o 9a f2JOB LOCATI
ASSESSORS
OIINER:
r.rAp*, l10)SLl?" rm
B,T
Lor*, S?0 C
ADDRESS:
CITY:
ADDRESS:
CITY:
848 \r-PIIoNE *r ? f6- 7/A 6
STATE:
BACKFL0II PERMIT rS $15.00 + $.75 (STATE SIRCHARGE) + $.45 (ADMIN. FEE) = 516.20
QYo HY:77
Q'--zrPz €4nZ
PHoNE *: fuZ-782/
CONTRACTOR:
(
Qrc-STATE:
CONSTRUCTION CONTRACTORS REGISTRATTON *Z /O/6?4 EXPIRES:qi
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPBCTION ONCE THE
BACKFLOU PREVENTION DEVICE HAS BEEN TNSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSo STATE THAT ALL TNFoRMATToN 0N THrS PERMTT/APPLTCATToN rS
CORRECT.
ZTPz f7n
8-2r-77ffi
FOR OFPICE USE
--r!------i
DATE OT APPLICATIONI
RECEIPT *:0)JOB #r
ISSUED BY:
TOTAL AMOUNT COLLECTED:
2
L,
//1.? t(,\_?7 'bo