HomeMy WebLinkAboutPermit Backflow Test 1996-6-6
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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OFFICE: 726-3759 .' .
INSPECTION LINE: 726-3769
225 FIFTH STREET
SPRINGFIELD OR 97477
JOB LOCATION: .~\ \\\8:"\\ ~
. ASSESSORS MAP #: /;>-<:92- ~,/-4t:>
TAX LOT #: ~e::>6"~::2
OIINER: E.C'Cn ~ ~2N(,,(,\
ADDRESS: \ s'\S .\..1\\qE\\lo\ ~ \ \ PHONE II:
CITY: <;:: ~ )(\.'2\,\<( . STATE: ~.
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ZIP: Q1LDi
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: +-Eu.uLf e PucE .
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PHONE II:JL\b~IL~ I
CJ(L. ZIP: Q7L/.Lf()
7-;; EXPIRES: /.b-~/-~
ADDRESS:
CITY: ~( ,\\<;'f\'L- STATE:
CONSTRUCTION CONTRA'dtORS REGISTRATION #:
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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SI~E ( . (I~"i~~\f\~
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DATE "-
FOR OFFICE USE
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DATE OF APPLICATION: (p I ~ I q(p JOB 1I: q~ "AG'~
RECEIPT #: :Zj~ /; ,. ISSUED BY: (\ .~'lo..do ' .
TOTAL AMOUNT COLLECTED: /I n :x'D
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