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HomeMy WebLinkAboutPermit Backflow Test 1996-4-5 --=. .~ \;(011:> BACKFLOY PREVENTION DEVICE PERMIT APPLICATION !If CITY OF SPRINGFIELD ' BUILDING SAFETY-DIVISION '" FlPTII "REST OFFlCE' ",-",' SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- 1'::>~_:sPz~-~ , .. ~ 'fvu 4<:'9-. JVv:~ /) () ~--a-~ ';.~ JOB LOCATION: ASSESSORS MAP ~: 9bct TAX LOT 11:~/~'"3 Ol/NER: Future " Hom.." ADDRESS: ,,,q, Rillpr pninh' Or CITY: Eugene ,PHONE ~: 4R5-1176 STATE: oregon UP: 97408 BACKFLOI/ PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20 CONTRACTOR: Hunter IrriC'ation & Landscapinq ADDRESS: .-J1,fw 4 <;4 ,PIIONE ~: 935-3215 CITY: "~nli'''i', STATE: nr~'}~n CONSTRUCTION CONTRACTORS REGISTRATION ~: 11 372 ~IP:~ ,EXPIRES:~ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOI/ PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TllIS PERMIT/APPLICATION IS CORRECT. _~~~~l. ~. . OAT!:: ~~ u -------------------------------------------------------------------------------- FOR OFFICE USE RECEIPT ~: 207 7} (/~/56 ISSUED IlY: /~ JOBu:.7~of.7 / .~~. , DATE OF APPLICATION: TOTAL AMOUNT COLLECTED: /c,.~ --------------------------------------------------------------------------------