HomeMy WebLinkAboutPermit Backflow Test 2000-2-7
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SPRINGFIELD
476
000
.00
CHANGE:
CASHIER: 059
BACKFLOV 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: J / t,L 7 /77 e:? /h :5 cr-
. ASSESSORS MAP II: 17-033 tf4/
OIINER: '/3' 't'r/7 / -e: # ~h? ~
/
ADDRESS: / / t/ 7/1"7t7 //7 1'/-
CITY:-,"}orfhj1',I>~/'/ STATE: ??r
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) +'$.45 (ADMIN. FEE) =$16.50
TAX LOT II: O?-ycLJ
PHONE 1I:~/8-s726'-/??2
ZIP: ~;7f/7:7
CONTRACTOR: 05 ~hI~/7y JnC--
ADDRESS: j? c:f Bd.l<' 2- / .7 ?'
CITY: J:;//#~J-? ~ STATE: 6l/'
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CONSTRUCTION CONTRACTORS REGISTRATION II: "~~~~~
PHONE 11:7' ?~~.fJ~V
ZIP: Y' 7 &or CJ z..
, EXPIRES: 7" ~~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALt 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. ' , '
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SfG~~-' r ,
'z-7-t?7J '
D1iTE
, FOR OFFICE USE
--------------------------------------------------------------------------------
DATE OF APPLICATION:
RECEIPT II:
TOTAL AMOUNT COLLECTED:
,JOB II:(J)-OO~(X)-d
ISSUED BY:
--------------------------------------------------------------------------------
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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: II ~ 7 )?7t!2//1 .,-r
" ASSESSORS MAP #:
OirnER: JJt'/Nl/e //Ud#'
/
ADDRESS: 1/ ~ 7 f??d/d <;~
CITY: <A7r/h/f/eU
;; I
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
TAX LOT II:
PHONE #:72675 ?Z--
STATE: ttJ/' ZIP:!'?f/77
CONTRACTOR: .V.?.5' //dth/6//7d' k~
,
ADDRESS: / tJ /Jdl/J '}j $"'1'
CITY: J5 I/dYP?1 b STATE: ,tlv--
1
CONSTRUCTION CONTRACTORS REGISTRATION II: t1t~~t1~,
PHONE 1I:~9"'5'"'-"<<1
ZIP:f7~z
, 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 THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION'IS
CORRECT.
~'/~~
- ~
SG TRE / r '
, 2- -- 7/ c7tJ'
DA'fE
, FOR OFFICE USE
--------------------------------------------------------------------------------
DATE OF APPLICATION:
RECEIPT #:
TOTAL AMOUNT COLLECTED:
JOB II:
i
ISSUED BY:
--------------------------------------------------------------------------------