HomeMy WebLinkAboutPermit Backflow Test 1998-1-28
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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
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BACKFLOY PERMIT IS $15.00 + 17~~(~~~SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: ~(\~I'0.(\;t()~ .,;ral!~ ~I "'9
ADDRESS: 9t-. ~ ~ PHONE #:
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CONSTRUCTION CONTRACTORS REGISTRATION !t: :;.
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PHONE #:
qf)l/ -05'76
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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.
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FOR OFFICE USE
DATE OF APPLICATION: I-:n ' q t
RECEIPT #: a-q: 0 ? () ISSUED BY:
TOTAL AMOUNT COLLECTED: ~/(n"~
JOB #:
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