Loading...
HomeMy WebLinkAboutPermit Backflow Test 1999-08-13f. SPRII{GF!ELD CITY OF SPR OBEGO'U BACKFLOS PREVEMION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SATETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 JOB LOCATION: ,115 &O+,'.- OFFICE: INSPECTION LINE: 726-3759 726-3769 ASSESSoRS MAP *: ll Oa 2411 >TAX LOT *: 0)- OUNER: ADDRESS: Jl-]? 6 tjo,nrt^n tll PHoNE *, 1,/1- 7-213 ZTPz q7 4'7'7cIrY: 5n PLL r\ e,STATE: OPea oni .. u U BACKFLOU PERMIT IS $15.00 +1.05 (STATE suRcHARcE) + $.45 (ADMIN. FEE) =$16.50 crrt:MTHORIZED UNDER THIS PERMIT tS NOT srA coNSTS{lgT$$DAryEHftSoRS REGrsrRArr0N *:@inceiniesiTT,Fe---7f i'-e*EE! calling rh* senr*r (htote: the tetepi'ione BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPBCTION ONCE THE BACKFLOW PREVBNTION DEVICE HAS BBEN INSTALLED AND IS VISIBLE FOR INSPBCTION (726-3769). r ALSo STATE THAT ALL TNFoRMATToN 0N THrS PBRMTT/APPLTCATToN rS CORRECT. 6- t3-11 DATE TE:_ZTP, _ EXPTRES: POR OFFICE USE DATE OF APPLTCATToN: € - tn-g 1 RECEIPT #: bS r>-"i ISSUED BY: .s?)TOTAL AMOUNT COLLECTED: +i) JoB#, q9 lrr 2)