HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION ~
225 FIFTH STREET OFFICE: 726-' ,5 '"
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769. -~
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JOB LOCATION: 9 \ Ll '~~.M if J}--> ~'~
ASSESSORS MAP #: /?...t:>""'3.-Z"':3-G"?C5 TAX LOT #: ~/~:3
OYNER:,Futllre B Homes
ADDRESS: 1'1Cl1 Hi "pr pni nt-I' nr
CITY: Eugene
STATE:
,PHONE #: 4R'1_1176
oregon
ZIP:
97408
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) c $16.20
CONTRACTOR: Hunter Irriqation & Landscapinq
ADDRESS: Rox 4'14
,PHONE #: 935-3215
CITY: ',"'-=':7, STATE: n~o~~~
CONSTRUCTION CONTRACTORS REGISTRATION it: 11372
,ZIP: Qi4R7
,EXPIRES: _ 'f. )() ~
BY SIGNING TillS PERMIT/APPLICATION, 1 AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TIlIS PERMIT/APPLICATION IS
CORRECT.
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DATE OF APPLICATION: 4/J/10 '/7 JOB II:' ~/C/?b ,
RECEIPT #: 20 'J 7.r 'I I ISSUED BY: d;;;' ,
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FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
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SPRINGFIELD
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION ~
225 FIFTH STREET " ,OFFICE: 726-37
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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, JOB LOCATION: 9/ l./ J'H. i#c.wz,,-<-. C~...tS" ~tf,
" ASSESSORS MAP #: /?_~'?.. 2 '::s -~ TAX LOT #: e-'~~
OYNER: r//"'?.-J7'7E ~ ~,..",,-- ;,'
ADDRESS: -?r;-~~:a/~z:;:>.,?//V7E m. PHONE #: Y~-5/:A<"
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CITY: Ct:/C::::;~E STATE: ~. ZIP: C?'J r~
\' BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) c $16.20
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CONTRACTOR: H u...;J"~.A' TA',(;Q",TT6_'
;;
ADDRESS: 2,,')..;;1.. t: S77ff<o-<-Af.....t/fv ;'.-./
,PHONE II: '93..r.. 3' IA.I S-
CITY: f./-<.~,~/'4
STATE: (9-1'.'
ZIP: 9 7.,,8-7
EXPIRES: 4-'3"-~(
CONSTRUCTION CONTRACTORS REGISTRATION it: / / '3 ') '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 '
"'(-2- f' ({
DATE
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FOR OFFICE USE
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DATE OF APPLICATION: t-/-7'~
RECEIPT II: ?~"7::::r ISSUED BY:
TOTAL AMOUNT COLLECTED: /6: ?,
JOB#: q?/S/~
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