HomeMy WebLinkAboutPermit Backflow Test 1997-12-16
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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 <g '7 0 ~4-;/I.J.r7'
. ASSESSORS MAP #: / '702- ? I c;1 I TAX. LOT #: I") / ;,:e; (J7 7
OYNER: MF-/~ --:'lRd-feJF ~#?es-
ADDRESS: '3 fb '7 t'? /7:? ?'f-- A.J PHONE 1I:
CITY: 5;1/7 STATE: ~ ZIP: ') 75176
BACKFLOY PERMIT IS $IS.OO + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:
IJ W ,(.J /2,--?
PHONE #:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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SIGNATURE- - , -. /'1
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: 12,/;0 /'? ')
RECEIPT jl: 2'8 2-'b{) ISSUED BY:
TOTAL AMOUNT COLLECTED:
/6 2,0
~~OB #: 97/73')
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