HomeMy WebLinkAboutPermit Backflow Test 2001-4-24
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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~:
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ASSESSORS MAP II: /?~} 2-1 c;l3 .
OVNER: 'M.,I< Wool I CCnj_
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ADDRESS:
CITY:
STATE:
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TAX LOT 1I:_/7nJ~,' 'r-'.~ 02.LTO?)
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PHONE II:
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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
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CITY:
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STATE:
CONSTRUCTION CONTRACTORS REGISTRATION II:
PHONE II:
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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. ' .
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SIGNATURE
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FOR OFFICE USE
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DATE. ,
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DATE OF APPLICATION: 4/2.-4/# /"
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RECEIPT II: s-af!- 7 ISSUED BY:
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