HomeMy WebLinkAboutPermit Backflow Test 1995-7-17
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SPRINGFIELD
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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: GJ 73 1l/J4A. t-lclG-<:
" ASSESSORS MAP iI: /703 :2 ~ /2..
OVNER: Ld 'S:!/ I//I/A tV
ADDRESS: 973 ,fLn/!-Th e..1 cl b(~
CITY: -::; r? tL-1 ~ i/~/)
STATE:
TAX LOT D: CJ 9' 3,;2.. 0
PHONE D: 7 ~ 7- q 0/0
Oe, ZIP: Cf7V 17
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: C!-A ~ '~~~,Ap /A.J3-
ADDRESS: pr). ~ Xi ">~( I PHONE D:
CITY: SPce-)/'-.3--~(b( J STATE: O~'-
..cONSTRUCTION CONTRACTORS REGISTRATION D: 5?;>/::J-
7 ~ /; -~tjt">-
ZIP: ---,97;7 7
EXPIRES: q- ~
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.' , '
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FOR OFFICE, USE
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DATE I 'j
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DATE OF APPLICATION:r/ ~S
RECEIPT D: / g '3 i / ISSUED BY:
TOTAL AMOUNT COLLECTED: ~~.JL 0
JOB #: '0',5"//9/
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