HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOY PREVENTION 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:
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.
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DATE OF APPLICATION:. i/s(J-:-
RECEIPT ft: 26)772- . ISSUED BY:
FOR OFFICE USE
. .d JOB 'U: "75'/~ S/~
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TOTAL AMOUNT COLLECTED:
/ ~ :.0
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