HomeMy WebLinkAboutPermit Backflow Test 1996-3-28
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD *
BUILDING SAFETY-DIVISION
225 FIFTH STREET OFFICE: 726-375
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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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
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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 {;
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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.
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SIGNA~ . /. a .
~;25?/9C;:
DATE' '
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FOR OFFICE USE
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DATE OF APPLICATION: '5 -2. & s:z::
RECEIPT 1I: ?~.@/ ISSUED BY:
TOTAL AMOUNT COLLECTED: /6. '<=
// "JOB ,~:' 9~Y'3Y'
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