HomeMy WebLinkAboutPermit Backflow Test 1996-5-10
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERHIT APPLICATION
CITY OF SPRINGFIELD
BUILDING.SAFETY-DIVISION
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225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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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
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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.
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SiGNAtURE
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FOR OFFICE USE
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DATE OF APPLICATION: 5) ) 0) q (p
RECEIPT D: 02-- I '179 ISSUED BY:
TOTAL AHOUNT COLLECTE~ 1LP. An
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