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HomeMy WebLinkAboutPermit Backflow Test 1995-7-17 . .:- SPRINGFIELD ., .' BACKFLOV 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: 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.' , ' ~ /!;:Y' SlG#~ tI FOR OFFICE, USE 7//7/QS DATE I 'j -------------------------------------------------------------------------------- DATE OF APPLICATION:r/ ~S RECEIPT D: / g '3 i / ISSUED BY: TOTAL AMOUNT COLLECTED: ~~.JL 0 JOB #: '0',5"//9/ ./ >r-t ' --------------------------------------------------------------------------------