HomeMy WebLinkAboutPermit Backflow Test 1997-3-14
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SPRINGFIELD
BACKFLOV 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: <./97</ /J1tU'" S-!-"eei
"ASSESSORS MAP fi: /70'0 3"$ 32
OVNER: F/ol'eA1u ()~
ADDRESS: 3'6 7 q La4'/k-fu-....
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CITY: ~p OR. 971(<> Z- STATE:
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TAX LOT fi: 64',;)0 I
.PHONE II: 34'3 - 1/'13
OR..
ZIP: '17voz.
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: t3 an-YIP c:, jJ, 'of T e..~ If lw,.,h Ik~
ADDRESS: 2'7 g 7 O~ """-f I~ il2. 'l PHONE 1I: I"Z.&' ~C; go ""-If
CITY: c,JU STATE: tS.e.. ZIP: 'h<(77
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CONSTRUCTION CONTRACTORS REGISTRATION 1I: 'j? ~ ~ (I ,EXPIRES: '5"1 HI 'f?
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIlAT ALL INFORMATION ON TlIIS PERMIT/APPLICATION IS
CORRECT.
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SIG'NATURE
DATE
'3/''1/'17
FOR OFFICE USE
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DATE OF APPLICATION: .3 -/'1-97 JOB #: 970377
RECEIPT jl: fb. q /&3 ISSUED BY: n. rYJIU/JI7../'j.{)
TOTAL AMOUNT COLLECTED: \!b / &. ;)-0
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