HomeMy WebLinkAboutPermit Backflow Test 2000-6-6
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TRANS#:01-0002044
000
.00
CHANGE:$ 3.50
CASHIER: 059
BACKFLOW 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: S'~O?-l /nA-1N - /J1J::~L .,4j/IM A-L U/A. J/(-
, ASSESSORS MAP #:
OIlNER: 5op.J{lJY lAJA-7')ON
ADDRESS: ("02, /1J-A7AJ
TAX LOT #:
CITY: STATE:
ZIP:
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PHONE #: 7L/7- ~T'l
BACKFLOW PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR:
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CONSTRUCTION CONTRACTORS REGISTRATION #: n,,~ :'r.; "" "
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR 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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ADDRESS:
CITY:
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EXPIRES:
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L;OMiVi6'~cUUNDE, -"r-'Relf:"f7../ DATE
I,Ny 780 NeeD OR /S R tHiS PeRM, l: WORk
DAYPeRIO ABANDON. YtlSNOt
FOR OFFICB-USE 'E:Df:OR
DATE OF APPLICATION:
JOB #: ~O'00g~S-01
RECEIPT #:
ISSUED BY:
TOTAL AMOUNT COLLECTED:
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