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Home My WebLink AboutPermit Backflow Test 1999-12-30 . .~ BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225,FIFTH STREET OFFICE: 726-3759 ~~~~~~:~:~~-~~-~~::=----------------,---~------------~~~~~:~~-~~~:_-~~~=:~~~-~ JOB LOCATION: n '3? m":'k_~'2/- C,f'-<-5~. 'h_ " ASSESSORS MAP II: 1'1 () 3 2~ LjJ c~~e~~t 5LI 0 0 " "f, ...~ v~ '0/)': )..- u.. -r,:;,A..... Kf' /...,l", __-<.>-s 'tt}-. ~~J_ ~~I'l O'..y.... 0'0 t.~<>. V4"~ P~ !ij:>' v~,(\ ~JOJ' ' ,Q~ );0' "~ '~ - STATE: tf:J~ ~O^ i94~ ~':~?y '7 ? , "vo;~-9~~'tt,Q BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE'9~rrfJ~ct OWNER: ADDRESS: CITY: S ;::?f:MJ:; ..{:.-{~ . CONTRACTOR: }-/UA''Ti~ I.A'/f'JcA~.,. 4 2J4A/L/ J<!-+P...... .r-~, ~ ADDRESS: ::? .,?-..:2.. C sT?f'&.......~~A'v 1 n/ PHONE II: CITY: 1/<A/~/:;4 STATE: /J~ CONSTRUCTION CONTRACTORS REGISTRATION II: J / ,~ '/ ;2 , ' ',ZIP: 9 7 J/fj-~ ,EXPi:RE~: y/.?~ 0 '''0 , u, 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. ' " ' cfL ,.. " ; , ' , /L:7' SIGNA URE ;.;<- 317 -9;; DATE .,". , FOR OFFICE USE ~-~-------------------------r----1-----~~--------------------------~------------ DATE OF APPLICATION: /1-13D q cr JOB II: qq09S2- , ' , 1:. 'Yl/1IA T()TAL AMOUNT COLLECTED: ISSUED BY: q, /(rrD RECEIPT II: , , -------------------------------------------------------------------------------- ~