HomeMy WebLinkAboutPermit Backflow Test 1995-9-22
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SPRINGFIELD
BACKFLOV PREVENTION DEVICE PERHIT 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: /h 2~ ~.A? /}f(/ .
ASSESSORS MAP #: /7-r:::J7~~t:::- ~/ TAX LOT #: &P3 Y.oO
OVNER: GY~C::;;C'~/d/d!r e6\(.s./.c~~
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ADDRESS: L:/~#e ~$ ~ ~ PHONE #: 7Y~-?"Jb-s-
CITY: --5~_ STATE: ~. ZIP: 4?Y'Z13
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADHIN. FEE) = $16.20
CONTRACTOR: })~A:/ -'5.#Y/.='"<'-
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ADDRESS: ?.(9.~ /,I1??5~~ PHONE #: 4~"'7 -'7~5'~
CITY: E/..;e::;~__......~ STATE: ~~. ZIP: ':::;?'/7t!>'Y'
CONSTRUCTION CONTRACTORS REGISTRATION #: /C?;;?J!!$~~. EXPIRES:JO~/-9?
BY SIGNING THIS PERHIT/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. '
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DATi::
FOR OFFICE USE
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DATE OF APPLICATION: q- -::2 2 ~~5"
RECEIPT II: /?//~ ISSUED BY:
:OTAL AHOUNT COLLECTED: J'~.~?'
JOB #: ql&)/?//
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