HomeMy WebLinkAboutPermit Backflow Test 1997-7-2
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SPRINGFIELD
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'" O\'ll\'ll\:.~C\:.\) <:~IOOlACKFLOII PREVENTION DEVICE PERMIT APPLICATION '*.
C ()~8 'Il<- CITY OF SPRINGFIELD
r>-~'{ ,e() BUILDING SAFETY DIVISION',
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225 FIFTH STREET OFFICE: 726-3759. '
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: h q q ?? />> A / h
.. ASSESSORS MAP #:- J 77YJ-SSZJ.
OIlNER: . f)1l Y I mLvl-
ADDRESS: kh y tfy..u.,h ft/IJr;f PHONE #: -9t9.P-233P
CITY: 71/1r...h'?h .?17 STATE: ~
BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
TAX LOT #:
s 3, I-::f-
ZIP: eo/74V'?jP
CONTRACTOR: j,~~"':r 1: :rtf
ADDRESS: a II e.?r /17 2 :5 Z- PHONE #:
CITY: ~/.4I'-1i?tP' STATE: ~~
CONSTRUCTION CONTRACTORS REGISTRATION #: ~~~
:7~~ /t-J/ //f#~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
~~-732/
ZIP: '7770/
EXPIRES: /#.P'/.~
_.%/Y?
Sic/MURE .
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L2u~A)J#/ "
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FOR OFFICE USE
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. DATE OF APPLICATION: 7/;;/97- ' JOB #: q 7/ D/7-
RECEIPT #: f)J(f}<;cr) ISSUED BY: ~- 1M ~ - .
TOTAL AMOUNT COLLECTED: ,,<I, / w-l- 0 '
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