HomeMy WebLinkAboutPermit Backflow Test 1998-6-10
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIZLD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: <i?-3o /?c.t!..~~.:L'~ C~......s-;-
. ASSESSORS MAP 11: I / b 3 2- 3 if .3 .TAX LOT 11: () Zoo 2-
OWNER: S I <,......4.1fT ;f ~C}
ADDRESS:
CITY: ~-Y a~,q r~,d
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STATE: I!),,(!
PHONE 11: 7'-/'7-836 ~
ZIP: q.'7~
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BACKFLOW PERMIT IS $15.00 + $.75 (S'~ATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: J-!..........-;-;....{' -p~~ClA-r.;"J d' I~MLJScA/---
ADDRESS:'). ..-:l 'J / J I /IA-"", ,e'......r A:/ ,( ~/ PHONE 11:
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CITY: /~-'_~ STATE: o;f!F
CONSTRUCTION CONTRACTORS REGISTRATION 11: I J '3 7 ~
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ZIP: f.)'7YJJ-'7
EXPIRES: ~hYtl-?')
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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NOTICE:
THIS PERMIT SHALL EXPIRE IF THE ~ , y
~UTIIOflIZeB lJl~Ul:H THIS PERM~iNOT -
COMMENCED OR IS ABANDONED FOR
ANY 180 DAY PERIOD.
FOR OFFICE USE
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RECEIPT 11: iJ36')-:;?. I 'ISSUED BY/}. rntJ..ch ad 0-
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TOTAL AMOUNT COLLECTED:
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