HomeMy WebLinkAboutPermit Backflow Test 1998-9-8
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BACKFLOV PREVENTION 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: ~o ~ ~LLJ oA'c#,&.<rCJ
ASSES SORS MAP #: /? ..11'3 -2'" C7=?
OVNER: .~ ,/ Lv~_;..~.,
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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) = $16.20
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CONTRACTOR: I-!U^I/~ I,;(~,1<:)-AI,c..v'..I" ,);?N.tJoS <:'14-?~
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ADDRESS:. :1, cJ..:LL ~~~/fV' 1.~ PHONE #: 9.1',r-- S:J../.r-
CITY: 1/.., ~...-.f?J- STATE: ~fi< ZIP: ~ '/$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.
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SIGNATURE
J-~:?y-
DATE
FOR OFFICE USE
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DATE OF APPLICATION: 0-g--?~
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JOB #: ~~///..s:<.
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RECEIPT U: ?/)~2 Y ISSUED BY:
TOTAL AMOUNT COLLECTED: /6_.2~