HomeMy WebLinkAboutPermit Backflow Test 1998-10-1
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SPRINCFIELD
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. BACKFLOV PR~. VE q~ DEVICE PERMIT APPLI~~~E.
' Oll laW requlrefdl .m SPRINGFIELD 1\;1;;.
ATTENTION:oreg d by the OlbrW-'FETY DIVI SION THIS PERMIT SHAL
~ow rules adopteThose rules are9s;2-OO1_ AUTHI'U:lJ,7.';.r.o. L EXPIRE IFTHE WORK
225 FI ~:f~lIter. Ug\'lOAR "YJt'NJI.\&rNDEm!~~~
SPRIN ~ ~.19J'ir~1?\\'Iro. ol\\'Ie rules by INSIlWII1J;nNltl,:r.Nlk.. J~ :.'~69RMIT IS NOT
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-----.JD---""'l'crcr1'\'l!l!f-Qh=---u.. '" ',t:.fT .,--------------------ir-------------- 0'" ..-""'CD FOR .
0090.. \\'I~\er. tNO e1il;;Ut,NO\\t\catloll ~ ~y lOr' f)rlY PF.RI0n
JOB LOCAT'f'Clij'~_.,,&0'~ego~~~~C-d/9A'<J ,
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.' ASSESSORS MAP <1I~"'n 03 d- 3 Lf- z., TAX LOT #: ()3/ (57)
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OVNER: 'FV-Tu."<'<..,,c.> /T"'--- _ ....,
ADDRESS: f! O. I~X /L/;)..S PHONE 1I: 7L-fq- ;}&f//eJ
CITY:. ~1C1)(Jrv--fL/ STATE: O~ ZIP:
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADI::N. FEE) " $16.20
CONTRACTOR: )/u~/--;-:c.y{> T'<.,f'/~.....a' Li4 _u:;)SCJ9,r'...........
ADDRESS: '2,,;>,,;:1..,5 ">/ /l-;"''''''.6:A'AV .14_, -... PHONE #:
CITY: ~~""""77P-
STATE:
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ZIP: 9::11; r,,?
EXPIRES: <'/-3&- 9:;7
CONSTRUCTION CONTRACTORS REGISTRATION #: J I.r 7--:J
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV 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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FOR OFFICE USE
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RECEIPT 1':03/ C? / f:"" ISSUED BY: 17. mo c.-tr o:do
TOTAL AMOUNT COLLECTED: / '& . JU
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