HomeMy WebLinkAboutPermit Backflow Test 2001-2-20
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DEVELOPMENT SERVICES DEPARTMENT
225 FIFTH STREET
SPRINGFIELD, OR 97477
(541) 726-3753
FAX (541) 726-3689
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: g9.~l/)?('k.JJ173--u. '(fLur
. ASSESSORS HAP #: /70323'-12 TAX LOT #:
OIINER: YJ)/JW r-r SfI.-!U)u A.......-'
ADDRESS: Ji"hl-"1 ~(bMJ7.A.L' 6)(/J{ PHONE #:
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CITY: +AbJ?~J! STATE: rQ:r'
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMIN. FEE) = $16.50
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ZIP &7</672.
CONTRACTOR: ~1<J'Uuo .J~c-rucu.L..di ~-on t',
ADDRESS: J4:5,~ uLkuJd.LA4 _ O./AL PHONE #:
CITY: hIIV-771) STATE: 627".
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CONSTRUCTION CONTRACTORS REGISTRATION #: L
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ZIP: q7V~
EXPIRES: I (J
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT_
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SIGNATURE ()
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DATE
FOR OFFICE USE
DATE OF APPLICATION: 02 zoo (
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JOB #:DO -00'108'-0/
RECEIPT #:
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ISSUED BY:
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TOTAL AMOUNT COLLECTED: