HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION
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OFFICE: 726-3759
INSPECTION LINE: 726-3769
225 FIFTII STREET
SPRINGFIELD OR 97477
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JOB LOCATION: q :5 Y . lrv- \<:c~ · ~~'l ~
ASSESSORS MAP ft: 17-b"}~Z-~.t!!>~ :rAX LOT U: ~/P,P"'3
OYNER: Future B 'fames
ADDRESS: l';Ql Ri vpr poi nl'<, nr
CITY: Eugene
.PHONE U: 4R<)_Cl.L76
ZIP: 97408
STATE:
oregon
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: Hunter Irriqation & Landscapinq
ADDRESS: Bo>< 4<)4
,PHONE U: 935-3215
CITY: \1011C~=. STATE: nrp'J.........
CONSTRUCTION CONTRACTORS REGISTRATION U: 11372
ZIP: 974R7
, .EXpIRES: 4/30/Qt,.
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLO\1 PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT! APPLICATION IS
CORRECT.
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FOR OFFICE USE
RECEIPT ":
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ISSUED BY:
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DATE OF APPLICATION:
TOTAL AMOUNT COLLECTED:
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