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HomeMy WebLinkAboutPermit Backflow Test 2001-4-24 . . BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 JOB LOCATIO~: -------------------------------------------------------------------------------- , ~/!f Old o~,,-L/ L, ASSESSORS MAP II: /?~} 2-1 c;l3 . OVNER: 'M.,I< Wool I CCnj_ <('ftf Old b,-J",.I /.... 'Si?,...,....J....(/ ADDRESS: CITY: STATE: f TAX LOT 1I:_/7nJ~,' 'r-'.~ 02.LTO?) 1/..-." . PHONE II: oK:. ZIP: 7' 7f7 ') . BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 CONTRACTOR:-:5L r ADDRESS: f? 0, is,,,x 7rf5"' CITY: 6A.t;t:-..t V STATE: CONSTRUCTION CONTRACTORS REGISTRATION II: PHONE II: oiC... ~33o 7<(Cf- 7(3 f ZIP: 7' Nol EXPIRES: -;z,6~02- 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. ' . D-~ Ak SIGNATURE r FOR OFFICE USE ~f/o( DATE. , -------------------------------------------------------------------------------- DATE OF APPLICATION: 4/2.-4/# /" ( ( '1 <- RECEIPT II: s-af!- 7 ISSUED BY: Z,/: rD ~ JOB II: Ob-e:lltd:l-tJ( ~ :I> -i -^/'v<. ~ '=' :;0 -to... .,- v :c>:D :;o-iZ nlT1[T1CfJ ::J:C"'J..# CJ::Dc:::J:D" :J>:Z:.. -00 -----------~------------------------------------------------------------------5e~~~~ .....-.4..-Eflf'..)O rT1.f:07 .p..o :;0 l.N 0 ..OI'..Jr-.JUl O. . 00 QU1 0 o.p.. uoot-'--:J TOTAL AMOUNT COLLECTED: