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HomeMy WebLinkAboutPermit Backflow Test 1996-4-5 ~ )1/e'p' .. . lA&\ 0 BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY-DIVISION ~ OFFICE: 726-3759 INSPECTION LINE: 726-3769 225 FIFTII STREET SPRINGFIELD OR 97477 -------------------------------------------------------------------------------- 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,. . 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. ~ ~~ ~DAT;/2-/9/- l\ -------------------------------------------------------------------------------- FOR OFFICE USE RECEIPT ": 2A 9 r_ "") f10~ ISSUED BY: 3/.~O JOBu:':9~f7('? /~" , \. If.?-D j)~/r IS. H> ~c/? DATE OF APPLICATION: TOTAL AMOUNT COLLECTED: -------------------------------------------------------------------------------- J