HomeMy WebLinkAboutPermit Backflow Test 1999-11-15
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SPRINGFIELD
W01UCE: PIREIF iHEWORK
iHISPERM\1SHALLEX SPERMlTISNOi .
AUTHOR~EDUN~~~~~~~~ION DEVICE PERMIT APPLICATION
COMMENCEDORISAB "CITY OF SPRINGFIELD
ANY 180 DAY PERIOD. BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: 'if"t5:7 t9 L.tJ IJ/fc..HAtr L)
.. ASSESSORS MAP It: /1 OJ 21 L{ '1
OIINER: . -;::-vQ 1A.."f...... ~ hi". - . 5
ADDRESS:
CITY: S/~~<;- 'p,-<..Ce:2
,
TAX LOT It: () 2,! l) V
PHONE lt~ 7'Yc.,/-::l.ChD
STATE: tf)~ ZIP: 9~l./"?
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR: J-jl.L~in.A IX,{'Je;A77P"" .J.: l>4..u7s&~ r^,c:..
ADDRESS: ~ <5-.;;l.;;! tC. ~19<<.-.,,1'dA'\/ .J."ln.____ PHONE It: 9..J'.r-3' .:u...r-
CITY: ?/...._^'_-r.- STATE: ~A'.e: ZIP:. 9'?Yr'7
CONSTRUCTION CONTRACTORS REGISTRATION I: J 1 ::?'l ;L. . EXPIRES: V -3t:J-oo
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS~V.ISIBLE FOR INSPECTION.
(726-3769). I ALSO STATE THAT ALL,INF8RMATION/'ON,l.'fHISJERHIT/APPLICATION IS
CORRECT. AlIEN1 U"'d~;t~d by the oregu"seti'~rth
. tallOW rules a Thos~ rules are ?-O01-
~og~~~~~~~~~~~i 0 thrO~~~ ~~~~;);uies by
10 0 You may obtain cOP. nE; H31ephO~e
. OO~";lina the cen~r: ~~~t~\li~IN NOtilicatlOn ./1- /-oJ'=-;;; 9
number lor ~1,,;;.v1:800-332-2344). DATE
. cen,911S. .
~/~~-
SIGJA~URE .
FOR OFFICE USE
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JOB It: qq (): ),.'
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RECEIPT It:
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ISSUED BY:
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DATE OF APPLICATION:
TOTAL AMOUNT COLLECTED:
Ie. )0
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