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HomeMy WebLinkAboutPermit Backflow Test 1996-4-5 . . BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY-DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: ASSESSORS MAP jj: qS-~. 'Yfu._~-+ ~ ~ M l"?~'--:Z ?~.?? TAX LOT jj: /,,)/Ob-~.~~..l~" OYNER: Future B games ,PHONE jj: 4R'i-1176 STATE: oregon 'lIP: 97408 ADDRESS: C\o;qC\ p;,'pr pni nt-~ nr CITY: Eugene BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) c $16.20 CONTRACTOR: Hunter Irriqation & Landscapinq ADDRESS: Bew 1\ 'i 4 .PIIONE U:. 935-3215 CITY: "'___"'. STATE:_n_~,?'C.- CONSTRUCTION CONTRACTORS REGISTRATION U: 11372 ZIP:~ ,EXPIRES: Lf /3 0 ~ BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE DACKFLOY PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS CORRECT. t~ ~~ ~~ :J/2-/-U -------------------------------------------------------------------------------- DATE OF APPLICATION:. i/s(J-:- RECEIPT ft: 26)772- . ISSUED BY: FOR OFFICE USE . .d JOB 'U: "75'/~ S/~ f~ .' TOTAL AMOUNT COLLECTED: / ~ :.0 . ' --------------------------------------------------------------------------------