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HomeMy WebLinkAboutPermit Backflow Test 1996-5-10 '. . SPRINGFIELD BACKFLOW PREVENTION DEVICE PERHIT APPLICATION CITY OF SPRINGFIELD BUILDING.SAFETY-DIVISION <' 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: &' -5.:< A/ 1 c.j! tJ c...4.J <1 A- .' ASSESSORS HAP II: II 03 dO--.::) I OIlNER: /f'E"t/ 'f .() ~/f c,P~ tZ-4 L LIEV' ADDRESS:. &.S';;>" A/ IC.# d c: -?'oJ' L1 ^- CITY: \>4?r}) STATE: t1 /L TAX LOT II: 0 I ~{)O PHONE II: 7517 -1..1 7...5 ZIP: 97 y 7 7 i. i BACKFLOW PERHIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADHIN. FEE) ~ $16.20 CONTRACTOR: 1<.61'0 ( f'< LL-I B ~ ADDRESS: (0 '3>2- /-...J ir...h 0 L M CITY: ~fl2.;}"').5+i'~UJ CONSTRUCTION CONTRACTORS REGISTRATION II: il2. . PHONE II: 7L-f7 - I~ '7 S- STATE: 01'2- ZIP: Q747.7 EXPIRES: BY SIGNING THIS PERHIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORHATION ON THIS PERHIT/APPLICATION IS CORRECT. r/~.~ SiGNAtURE ~//& Ie; ? <' FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 5) ) 0) q (p RECEIPT D: 02-- I '179 ISSUED BY: TOTAL AHOUNT COLLECTE~ 1LP. An JOBft:'cr &nS().3 (\ . {Y'l a c-h Clel 0 -------------------------------------------------------------------------------- ."" J'