HomeMy WebLinkAboutPermit Backflow Test 1996-10-21
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SPRINGFIELD II
BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: f,13" /J1c/(",I7Z;e, (Y(Sf U/~Jf'
.' ASSESSORS MAP 11:/7/)3 ,.)2. 000
OVNER: {In:JJISlA.J ~ JJ" (<bn~A<j 7
ADDRESS,: I)(L? f3. /5Th
,,-.
CITY: 1:uavnl_
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BACKFLOV PERMIT IS $15.00 +'$.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: l"?tmrkl/-I-/I1#Y filM;/" IYY}Clhhn ~ Aonj\r~~/. L
I '
'i: fro u,JhPrr/l t. n PHONE II: ?55- I J 7 L/ .
STATE: f),{?"- ZIP: ?1t.f!7
/ / .~ 7,2 EXPIRES:
TAX LOT #:
loo!?
PHONE II:
LIES Lf - 0070..
STATE:
I]y?-
ZIP:
ADDRESS: _d'i 2:) 10
CITY: ')n,/I in
CONSTRUCTION CONTRACTORS REGISTRATION #:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769), I ALSO STATE THAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE ~. ~._..,-
/ () - .,;z / - 9/"
DATE
FOR OFFICE USE
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. DATE OF APPLICATION:I () ~ 0-1- 7 (.:?
RECEIPT II: Od: 5.5'i.3, ISSUED BY:_/7
TOTAL AMOUN~ COLLECTE~/(d' ~
JOB II: 9~ O/.5~
/YlN-~.-h ~d- )
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