HomeMy WebLinkAboutPermit Backflow Test 1994-8-12
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY .oF SPRINGFIELD
BUILDING SAFETY DIVISIDN
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3
INSPECTION LINE: 726-
JOB LOCATION: c:;;/C M/7A'5}\'/~
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. ASSESSORS MAP 1I: /;/"t?"'3' -=< '3 - 3 $I' TAX LOT 1I:
O\INER: 'l?~.?~ tfL/C-L.
ADDRESS: ~~~~ PHONE #:
CITY: <'PTt:.-/.2. STATE: C3/,?,
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7V&/-6'~
ZIP: s?'7Y~
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BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ~PcL7#--~~~~~~c- ;:?~/0- ::'>"/:CP'-~ ...
ADDRESS: ~77 ~?7"#~- PHONE 1I: 6&g--'7/YS/
CITY: Ec..r-c::i € ~ STATE: ~~ ZIP: ~ ~~-y
CONSTRUCTION CONTRACTORS REGISTRATION 1I: //.67"'~ EXPIRES: //-3t:P-<7'T
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FDR AN INSPECTION ONCE THE
BACKFLOW 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
RECEIPT 1I: I' LJ~~
ISSUED BY:
JOB 1I: .::::? V/2'?:?
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DATE OF APPLICATION: is-po '7' y
TOTAL AMOUNT COLLECTED: /6. <c;.
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