HomeMy WebLinkAboutPermit Backflow Test 1998-9-8
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD ~
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-375
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: g-~- /n<::."k:".M -::::1.1... ~<-.s/
ASSESSORS :-lAP #: J '/ V:?~, '2. ~ ~
OVNER: . "./--u~vf>... ~" 1#-.-__..5
ADDRESS: \) (C) \?Yx. ~4iL ~
CITY: rn~1\L
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =
TAX LOT #: ~:?~~
11M PHONE #:]14.
~~ ZIP:
STATE:
$16.20
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CONTRACTOR: J/UN I <:A TIf~c,.I4//:...r ..t .l;t};JLJ.r~--<--
ADDRESS: d~;>.A~ ~~L./f/f,/!..:r PHONE #: 93f-::'j~J-
CITY: },4.,..,.......J rJ STATE: &vf? ZIP: 5'?Vtr;?
CONSTRUCTION CONTRACTORS REGISTRATION II: / / .f?:2 EXPIRES: t./-3o-? J
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKrLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). ' I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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DATE
FOR OFFICE USE
DATE OF APPLICATION: :l..:8'-9g
RECEIPT jl: =j'/3~ ~ ISSUED BY:
TOTAL AMOUNT COLLECTED: . /6.;2.-
JOB #: ~R///?
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