HomeMy WebLinkAboutPermit Backflow Test 1998-7-23
.
.
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
--------------------------------------------------------------------------------
!
I
Ii
/
JOB LOCATION: 'fi'-cF.3 ~1r7 ()/f'c)./K1/f'LJ
ASSESSORS MAP II: I '7 tJ i ? 1, 4 J,
OYNER: 12/P/fv.E ~~.:... 2:." rJ
ADDRESS: ?.s-3 oL/J -oA'e.hlAAL)
TAX LOT II: 6 ).~ I
CITY: S~""~ -C, ,..J /')
STATE:
PHONE II: 7 y ,,( - :::J. '/ ~ l!/
.-9.ff'.E ZIP: <7)7 0/7 /'
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
J.-/ u ^' 7r .;?
, ,
2::A/?/aA7k^' .d" J ;4~u:::JSc.4P~
, -
ADDRESS: d Q :J...::<'C S/A?;."",~A'/?./ 1...,r PHONE II: 9ro-=- 3;;z /.j-
CITY: J/-<.^,~--r-=t.. STATE: @,(E. ZIP: '774/ If..?
,
",
CONSTRUCTION CONTRACTORS REGISTRATION II: J J ~ /' 2
EXPIRES: -1:::301' 51g
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN I~STALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
L~<-< 7L/C::-
S.!.G!')il.TURE
?-;;;. (j-;;?
DATE
"
FOR OFFICE USE
--------------------------------------------------------------------------------
DATE OF APPLICATION: "7- ?-3 - 9 ~ .
RECEIPT II: ()31)!f7...2 ISSUED BY: 17.
TOTAL AHOUNT COLLECTED:\.<I/ 1&. '21v
JOB II: '1 (01 J J-
{'(Iti-c.hMU .
-------------------------------------------------------------------------.-------