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HomeMy WebLinkAboutPermit Backflow Test 1998-9-8 - . . --~- BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: ~o ~ ~LLJ oA'c#,&.<rCJ ASSES SORS MAP #: /? ..11'3 -2'" C7=? OVNER: .~ ,/ Lv~_;..~., / - ADDRESS: ll'S-/r ()l;::J ~A'C>>.4A'LJ CITY: f;>j?/?,,:q.A'_L~ STATE: 69~ TAX LOT #: b:Z/.?~ PHONE #: 9ft'7?"-..r6'8-t:,. ZIP: '77 Y7-Z BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 , CONTRACTOR: I-!U^I/~ I,;(~,1<:)-AI,c..v'..I" ,);?N.tJoS <:'14-?~ - - ADDRESS:. :1, cJ..:LL ~~~/fV' 1.~ PHONE #: 9.1',r-- S:J../.r- CITY: 1/.., ~...-.f?J- STATE: ~fi< ZIP: ~ '/$I;r? CONSTRUCTION CONTRACTORS REGISTRATION #: J /3 '7 ?-... EXPIRES: Y-3t9-~"'" BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRICST. -~;?~ SIGNATURE J-~:?y- DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 0-g--?~ , JOB #: ~~///..s:<. ~~~ . RECEIPT U: ?/)~2 Y ISSUED BY: TOTAL AMOUNT COLLECTED: /6_.2~