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Home My WebLink AboutPermit Backflow Test 2000-1-26 (2) . . 225. FIFTH STREET SPRINGFIELD OR 97477 OFFICE: INSPECTION LINE: 72'_* 726-3769 BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION -------------------------------------------------------------------------------- JOB LOCATION: /cJ/CJ /?lcV;W ~/. ~J .k?/-<-~ '/ TAX LOT II: &./.b/7"~ 7 .' ASSESSORS MAP II: O\INER:?tmL J?M//~ ~.~ J?,.,dz;"" v ADDRESS: . CITY: ~~/ /t/ BACKFLOV PERMIT IS $15.00 + 1. 05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50 PHONE II: STATE: /Y/2 ZIP: 97177 CONTRACTOR: /ZIP/4:>C" /7 uL ~~ - .;/ ADDRESS: 7..--7 ff 7 AbA4-"'u ;iC?7 PHONE II: /' / - /' j- CITY: 7'72/f'(;l/A STATE: &R . / c/ CONSTRUCTION CONTRACTORS REGISTRATION II: /) >r~ 3/ ( n8t1- - //lrC 726 -~.?V ZIP: 9'71--77 , EXPIRES: ~ - 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. .' .~ .....AU~.. . / SIGNJ).T REI' ./~ .... '.';/26 /Oe . DATK . / . FOR OFFICE USE -------------------------------------------------------------------------------- \1 RECEIPT II: ) 6' is TOTAL AMOUNT COLLECTED: ISSUED BY: Pr.6,";0 . JOB II: 00 .00 II~- 0\ lUt.trJ.y ~...l '" A \ J DATE OF APPLICATION: lid-bloc.. -------------------------------------------------------------------------------- \ . . ~ '