HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOII PREVENTION DEVICE PERMIT APPLICATION ~
CITY OF SPRINGFIELD
BUILDING SAFBTY-DIVISION
225 FIFTH STREET OFFICE: 726-3759~'
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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ASSESSORS MAP II:
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JOB LOCATION:
OIlNER:,Future B I1nm.."
ADDRESS: Vi1n Ri vpr Pni nt-p nr
CITY: Eugene
PHONE II:Jfl"- 'I17/i
STATE: Oregon ZIP: 97408
BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: Hunter Irriqation & Landscapinq
ADDRESS: Rnx 4 'i"
,PHONE II: 935-3215
CITY: H.- __.. ~ STATE:
CONSTRUCTION CONTRACTORS REGISTRATION II: 11372
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ZIP: q74R7
,EXPIRES: . L{ /30 /'02..
BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECnON ONCE TilE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT. .
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4/7- / ttt,
DATI>
FOR OFFICE USE
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RECEIPT II: ?f)5'74 ISSUED BY: 4Y~'
TOTAL AMOUNT COLLECTED: /~?-o I
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