HomeMy WebLinkAboutPermit Backflow Test 2001-7-19
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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
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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-
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CITY: S /J-f:'}~ .t:'..J~ STATE:
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PHONE 1I:
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ZIP: 9 7'1' /,7
BACKFLOY PERMIT IS $15.00 +1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
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CONTRACTOR: 'ZL,,7</ LAX"/9J7b~/..I /#"'~ .5'eJ?/V\..
ADDRESS: ~ ~.:L2C ~I!'-d/-<.". 2.-./ PHONE 1I:93.s-j,;)/.~
CITY:
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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. .'
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SWNATURE
. 7-/9- 6'/
DATE
FOR OFFICE USE
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DATE OF APPLICATION:?/; ~/
RECEIPT ll: hi <J ~ ISSUED BY:
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TOTAL AMOUNT COLLECTED: