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HomeMy WebLinkAboutPermit Backflow Test 1996-3-28 . . ~' I BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD * BUILDING SAFETY-DIVISION 225 FIFTH STREET OFFICE: 726-375 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: ~q6/! ' /J14/6tJ 57 .' ASSESSORS MAP ft: /?0::?-3"<?- r-/ OIlNER: b~'-IS GA~ C/vT'f2- ADDRESS: c.; L/ L( / '/J1 J / ~ CITY: 5.p.e:-)~(J TAX LOT ft: O.h'7~ STATE: PHONE 1I: 7'1 -;J- ?-~ I o.f-.- , ZIP: C) 717 "7 " BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: a~t->Y:; L-AO'--.JJ~fJr:2R ~c.ec? ~ ADDRESS: /? O. &-0..)( ~"5-/ f PHONE 1I: 7t/.6-~!/?f5-- CITY: St??-'.J ~t/ti STATE: De. ZIP: Q7'177 CONSTRUCTION CONTRACTORS REGISTRATION ft: 5'::; / ;).- EXPIRES: j () /'7 {; , BY SIGNING THIS PERMIT/APPLICATION, I AGREE'TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS CORRECT. . ()Pffi1'~ SIGNA~ . /. a . ~;25?/9C;: DATE' ' -- FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: '5 -2. & s:z:: RECEIPT 1I: ?~.@/ ISSUED BY: TOTAL AMOUNT COLLECTED: /6. '<= // "JOB ,~:' 9~Y'3Y' /' .---?~-' 7/ -------------------------------------------------------------------------------- '",- )'