HomeMy WebLinkAboutPermit Backflow Test 2000-4-5
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SPRINGFIELD
143
000
.50
CHANGE:
CASHIER:001
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759~
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: ?'"Ah /4(A_K~_,=":'- C/~.5 r-
- ASSESSORS MAP II: / 7 () 3 :;)3 tm
OVNER: 'J1l."k-~ &71....e
TAX LOT II: 0/000
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ADDRESS: :r2 t: M-tLK<_,-=-,_ crf'.o .:/r- PHONE II:
CITY: .sHB~.,.J7H.L'/.l STATE: 19/
ZIP: '7 '7 '/7-'/
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR: jju..//",A" _T/f"{:,,,.JT7__ ..E ~NblJ~#~--<'"
ADDRESS: ::J ,J:2. ~ If{" '" t' /iJ...~~A"/?/
CITY: tJk N-c..r-A
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PHONE II: 91'.<- :3",;2../,5-
<!JA ZIP: 9;N/~:>
STATE:
CONSTRUCTION CONTRACTORS REGISTRATION II: ) /3:)2
EXPIRES: t.;-.1'&-<7<7
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV 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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DATE
FOR OFFICE USE
DATE OF APPLICATION: q -5- 00
RECEIPT II: ()6nJI!f3 ISSUED BY: /),
TOTAL AMOUNT COLLECTED:Q1 I Co . 66
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JOB II: qqOO 953-01
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