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HomeMy WebLinkAboutPermit Backflow Test 2001-7-19 . . SPRINGFIELD BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: ~I ~/ ,r)!-d lJA'c.JM.;<..d ASSESSORS MAP ll: I 7 D'], 2-"3 <i 7, OYNER: &tL::? ~J..I,;Lk$ ADDRESS: );-<;l/ it> L/J ",,,{><,-A1d,f/'J TAX LOT ll: t02/D;2- , CITY: S /J-f:'}~ .t:'..J~ STATE: , PHONE 1I: It'JI"f ZIP: 9 7'1' /,7 BACKFLOY PERMIT IS $15.00 +1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 , CONTRACTOR: 'ZL,,7</ LAX"/9J7b~/..I /#"'~ .5'eJ?/V\.. ADDRESS: ~ ~.:L2C ~I!'-d/-<.". 2.-./ PHONE 1I:93.s-j,;)/.~ CITY: l/"'-~/-<--"-A- STATE: r:9 I'f' ZIP: '7'7nJ'7 EXPIRES: S'- '" 2 CONSTRUCTION CONTRACTORS REGISTRATION 1I: ! 13':72 BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. .' p/J ___- / I~ /h--C- SWNATURE . 7-/9- 6'/ DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION:?/; ~/ RECEIPT ll: hi <J ~ ISSUED BY: /J JOB~: O/-W7~)-QI #/Pt ~o:;j DD ::u -t z rn rn CJ) C"J.. # C"J OC-...l.. D .. co (tJ r-..:tr.....,. ______________________________________________________----------------------~-- I . ......-tC")f:4........O rn::c ...010 ::::0 :D l.N c) .. ZGJr-JO' .OCi). 01--'- ornoo....o Lo.J." ot-"'Q /t:.,Fo TOTAL AMOUNT COLLECTED: