HomeMy WebLinkAboutPermit Backflow Test 1996-10-2
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SPRINGFIELD " I
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD ~
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: '16 ! /tAt:<<._ Z. ,'t: C~'5" f
ASSESSORS MAP II: , / Os )3 (JOD I () 3
OYNER: J=: .,C. ~ I-/. ~. s
ADDRESS:
CITY:
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SOr,L?~ 1'/ (JIL STATE:
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Or,
TAX LOT II:
PHONE II: 48'5 -- 317 ~
ZIP: 't'7c17T
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: 'S..-~ /S It.. ~ t:e-.I "r '" jk
ADDRESS: 40' 9.0 J&(, 1/._ .:, /-L~
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STATE:
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CONSTRUCTION CONTRACTORS REGISTRATION II:
CITY:
I z./ 70
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PHONE II:
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ZIP: '17'f7?
EXPIRES: '8/Jf/97
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TIlIS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE
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FOR OFFICE USE
1'1>-1--1"
'DATE
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DATE OF APPLICATION: 10- ,).. - (j V
RECEIPT II: D d 3'3 Lf ~ ISSUED BY i --1\ .
TOTAL AMOUNT COLLECTED:.~ I (IJ: ,d-r)
JOB 1I:.1!e..1 ~.3 "-1_
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