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HomeMy WebLinkAboutPermit Backflow Test 1997-10-16 . . SPRINCFIELD II , ~O~ ,\y..~ ~O'\ ~ ~ &\ \~ ~~\'?I- ~~'?-~ fcO'?- ~~.BA~K~ ~1~ DEVICE PERMIT APPLICATION ~\V ....<;.:";l;\~i'?- .o.~~Y-OF SPRINGFIELD ~O '?~'?-'" ((,\> \j~ \~ WUILDING SAFETY DIVISION . ~~'~ ~:D O'?- ~. 225 FIFTH STR 0 ~~\> ~(j OFFICE: 726-3759 SPRINGFIELD okl 9~ ~o\,~~ . INSPECTION LINE: 726-3769 --------------~--~~--------------------------------------------------------- JOB LOCATION: ~LJ.' AA.~v~ ~.,'e C..."..j. f)h 75D-?/eI. '1 ASSESSORS MAP U: -0 n i=:-k.... ADDRESS: L ~ q 3> CITY: fill 0 BACKFLOW PERMIT IS $15.00 + $.75 '" OWNER: 32-3 4WO ~0 ()-7) R /-h,,,,,,, ~ ~'v..vc ~" . - ,--r,_ ~ TAX LOT U: %C; - 3/7 ~ . ZIP: q-71./-6~ PHONE U: STATE: () f!-- (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 ?L~ I~k.;k (""-~O" /.J-t) (, R () AA. G l(..~...\- S/J..t/) CONTRACTOR: ADDRESS: CITY: T ",;''y...!L.t.'c.. v PHONE U: '.k,"', 04- ~~'1 STATE:.' O,e" 71/-i/-C-7/,~.5 ZIP: 971/.78 EXPIRES: 7S/~ J I~?f I I CONSTRUCTION CONTRACTORS REGISTRATION U: 12--/70 BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR .INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIllS PERMIT/APPLICATION IS CORRECT. K-~ SIGNATURE- ~J/~ / 10 /I6J~7 DATE / I FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: RECEIPT U: /)..713, TOTAL AMOUNT COLLECTED: I ()-Ilo-CJ, --- JOB U: <<17 OhD..'\ ISSUED BY: $ 1(", ~6 9<cJ -------------------------------------------------------------------------------- ~