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)
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