HomeMy WebLinkAboutPermit Backflow Test 1999-07-285PF'I JGFIELCD
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BACKFLOU PREVENTION DBVICE PERHIT APPLICA-' ON
CITY OF SPRINGFIELD
225 FIFTH STREET
SPRINGFIELD OR 97477
OIFICB:
:.ION LINE:
726-3759
726-3769
JoB LoCATI0N: 272f
OREGO'VC'TY OF SPR
ASSESSORS MAP II:l1 o324 2
OIJNER:J
L PHONE 1I 7/7e ///
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TAX LC:. *:1cloc
ADDRESS:
CITY:ATEr O ZIPz
BACKFLOII PERHTT rS $15,00 + \.O5 (STATE SURCHARGE) + $.45 ir,Dttrtt. rEE)
CONTRACAOR:
ADDRESS:
lOru:urey ort raw IcqUlres YOU tO
n
CITY:obtain rules by
rheteTepmffi-
CONSTRUCTION Ittility Notific?tion -- EXPIRES:
, center is 'l-80[t-33?-2344).
By SIGNING THIS PERHIT/APPLICATIoN, I AGREE T0 CALL FoR AN .TNSPBCTToN oNCE THE
BACKFLOU PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBl-I FOR INSPECTION
(726-3769). I ALSo STATB THAT ALL INFoRMATToN 0N TrrIS PER,,|',|IAPPLTCATToN rS
CORRECT.
FOR OFFICE USB
r.
DATE oF APPLrcATroNr t lyt 1f UJ'n: f ?0,1
RECEIPT {I:07n8 ISSUED BY:
TOTAL AMOUNT COLLECTEDI
ISAtrAI\UL,IIEIJI t'!I
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Iollow ftnels augpteu uy tl It, \rIr'gvr I uritlly
Notification Center. Those rules are set fo$figNg i1 ,
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