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HomeMy WebLinkAboutPermit Backflow Test 1998-1-28 . -----..J .' SPRINGFIELD BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 JOB LOCATION: ?'~4~ l"f'-c,,',f\ S:i-. ~()r'\'na~i5.\c\\O~ .. ASSESSORS MAP #: /70d~ 14;)"" 06 361:> ~ TAX LOT #: OYNER: t')' D. rYI e. '5'-. ~6v-.sc:>~ . ADDRESS:..!l1() /5! ~?t~~~. \(- () CITY:<\:::^0\'ri:'-\i~l~..~ ~\,~~, . STATE: c?>(L ~ V .ct!1'k .~\ " . O~ Oc:;,\ BACKFLOY PERMIT IS $15.00 + 17~~(~~~SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 ~~1lio 0. "Q -ro~ ~~., . CONTRACTOR: ~(\~I'0.(\;t()~ .,;ral!~ ~I "'9 ADDRESS: 9t-. ~ ~ PHONE #: 'b '/' ~ -$,T1fl.F. !?O, .~ 00'76 "F CONSTRUCTION CONTRACTORS REGISTRATION !t: :;. *, ,,"' '.' PHONE #: qf)l/ -05'76 ZIP.f1:W'J g CITY: ZIP: EXPIRES: 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 THAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS CORRECT. ~E ) ~;iPf3 ~ 9 @3 FOR OFFICE USE DATE OF APPLICATION: I-:n ' q t RECEIPT #: a-q: 0 ? () ISSUED BY: TOTAL AMOUNT COLLECTED: ~/(n"~ JOB #: ctC (,(j ,'/ So-Y'- eft ' ---;--/- q {.I 3~ 1 '