HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFeTY-DIVISION
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OFFICE: 726-3759
INSPECTION LINE: 726-3769
225 FIFTH STREET
SPRINGFIELD OR 97477
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JOB LOCATION: q-r3.. Ynr-.-~)'^+--' C~ ~
.' ASSESSORS MAP Y: J?~~- :?"'3"-=~ :rAX LOT Y:- ~/~-.3
OVNER:,Future R 'lome"
ADDRESS: 1'i'l3 Ri ver Pni nt-e nr
CITY: Eugene
PHONE Y: 485-3176
~IP: 97408
STATE:
Oregon
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) .. $16.20
CONTRACTOR: Hunter Irriqation & Landscapinq
ADDRESS:~v 4<;4
,PHONE Y:. 935-3215
CITY: uQn.':i: STATE: nro'J.....n
CONSTRUCTION CONTRACTORS REGISTRATION It: 11372
ZIP:~_
,EXPIRES:~
BY SIGNING TlIIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TlIE
DACKFLOV PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TlIAT ALL INFORMATION ON TlIIS PERMIT/APPLICATION IS
CORRECT.
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DATE
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FOR OFFICE USE
DATE OF APPLICATION: ~ 0' h
RECEIPT Y: '2-00/ ? / ,ISSUED BY:
TOTAL AMOUNT COLLECTED: /c,.oz..o
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