HomeMy WebLinkAboutPermit Backflow Test 1997-2-4
.
.
SPRINGFIELD
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
JOB LOCATION: /4-/1/ $/.b~/ ~f
. ASSESSORS MAP #: //03 C}./:) 33 TAX LOT #:
OYNER: JJJ 1..//24 .~ /:;9'/
ADDRESS: /~;,; /~.&-T kf
CITY: .C;/~:/ /I!!: ';:/&,./J STATE:
C), -S--SOO
PHONE #:
/J.P
ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: .i{./- .!-/'?? &//r:~
ADDRESS: }"B'9;2",? 5~/"y ~//,f},P jJ;; PHONE #:
/' '"
STATE: ,/JJ:2
/ ~,~-L
CITY:
. &:-#r::;d//
?#t339?
ZIP: q-74t?6
EXPIRES: /-;3/- ~8
CONSTRUCTION CONTRACTORS REGISTRATION #:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
SIGN~/ / ~/~~L
7- - .f-"J'7
DA'l'J::
FOR OFFICE USE
--------------------------------------------------------------------------------
DATE OF APPLICATION: ,]..-L/ -1'7
RECEIPT 11:[)lLfLl95f- ISSUED BY: /J .
TOTAL AMOUNT C~L~ECTED: J /fl1')v
,
JOB tI: Y7() 'J-/&
/Y}fJC!h ~O
--------------------------------------------------------------------------------