HomeMy WebLinkAboutPermit Backflow Test 1996-12-26
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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: 3 2D S- Yn~ ~~.
" ASSESSORS MAP II: /702- ~ / 3 I
OIINER: RrreP.';; 4z,...f?J ~d...b'"
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ADDRESS: :,:z..0"'S '--r'Vl.~ '3-,
TAX. LOT II: 1'0 ~0t!:To
PHONE II: 95'6 -9b ~ '3
(5) I{ ZIP: 97'17 f?
c:., .P1-~
7- 0
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CITY:
STATE: '
CONTRACTOR: J3~ J.h~ /'<e-c.-4 'If:> ~,~
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ADDRESS: .;l.., Y>'1 0 ~c.. ~ 2. &- PHONE II:
CITY: ~q STATE: 1'J't<
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CONSTRUCTION CONTRACTORS REGISTRAT~ON II: 0 y-~~ (t
72-10-7 s 'S'-/
ZIP: 9?'I7?
EXPIRES: '5/'Z--Z-/97
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 TIIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
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DATE .
SIGNATURE
FOR OFFICE USE
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DATE OF APPLICATION: / 2./2~/9r.;.
RECEIPT II: W/h Z ISSUED BY:
TOTAL AMOUNT COLLECTED: / b,-2..0
JOB II:~/ 7t:?&
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