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HomeMy WebLinkAboutPermit Backflow Test 1996-10-2 -. .r 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 -------------------------------------------------------------------------------- JOB LOCATION: '16 ! /tAt:<<._ Z. ,'t: C~'5" f ASSESSORS MAP II: , / Os )3 (JOD I () 3 OYNER: J=: .,C. ~ I-/. ~. s ADDRESS: CITY: f t I ../Vtc K.. ..'. {' ~c-~ /J;. SOr,L?~ 1'/ (JIL STATE: , J 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~ 1 STATE: )",,c/./ CONSTRUCTION CONTRACTORS REGISTRATION II: CITY: I z./ 70 v- :r".",;~ .J..'b_ PHONE II: 'r...... ()[ 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. A-~ SIGNATURE ).L# FOR OFFICE USE 1'1>-1--1" 'DATE --,----------------------------------------------------------------------------- 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_ Ma.r t..a do'