HomeMy WebLinkAboutPermit Backflow Test 1998-1-12
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 5703 J0141'-' ~1-
. ASSESSORS MAP 11: /?"'<1>7--=s~-~/
OYNER: W"'$L"'1 L.. t11"'J....../ ,C.H ':" &.~ 1
ADDRESS:.J1.fl .r"'-~J A-.
CITY: 5 g, tt/. . STATE:
.TAX LOT #: .c:/'3 '7'&'c>
.PHONE #: ~6 q.{. { 116 tu;..
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ZIP: ~/I UJ( .
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: LP....
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ADDRESS: S Ii! _ I.J& < L"""", '" .L " ....k...J 150
PHONE #: _<'SZ8 -Z2.,i -OSOb
CITY:.1:J-+I_...1
STATE: a....
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
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DATE
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FOR OFFICE USE
DATE OF APPLICATION: / -/2.~
RECEIPT II: 2~~~/ ISSUED BY:
TOTAL AMOUNT COLLECTED:
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JOB #: &?~??/
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