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HomeMy WebLinkAboutPermit Backflow Test 1997-5-16 -... . . .J BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION ~ 225. FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: ,7~/71) In/7./A?. .JIcnr .. ASSESSORS MAP #: /7&7 L'? 3 _? 2- OYNER: O/W,.-r.-J12- R_~~J< - ~ ADDRESS:.. '32>11.> l-/~.."k CITY:~j-,'nil TAX LOT #: ~ Z~~ STATE: PHONE #: 0--c 7;/(,- 7;:J.o ~ - WOy/<. 7.y&-4.'I1~ -....-Ro_-c:. ZIP: CJ7<1?7 BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE~ = $16.20 CONTRACTOR: -b; .~ ,.th;;~.--1L ADDRESS: ., PHONE #: CITY: STATE: ZIP: CONSTRUCTION CONTRACTORS REGISTRATION #: EXPIRES: '\. BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. "~~4j? _!5/~ C;/97 DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: '0~/~ Z $f!!,(S- ISSUED BY: /t~, 2-0 .AAr\J~~ #: ~7o 77S- d ~4->~ / t - RECEIPT #: TOTAL AMOUNT COLLECTED: -------------------------------------------------------------------------------- ~