HomeMy WebLinkAboutPermit Backflow Test 1999-10-12
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SPRINGFIELD
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: 1;-'; '7 & LLJ t)&h44/l<J
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" ASSESSORS MAP II: / 1/)~ :n.2 tt.J. () ),:1 ~ T~IllIg.p~~T~I-JAII I=l(PII=lI= II=Tl-JI;WORK
OVNER: ',::;}; {.....,( --<- ~ d hJ.,~ ..s AUTHORIZED UNDER THIS PERMIT IS NOT
() 0 " vUIVlIVIl:I~\A:U UH I;:' AtlAI~UUI~cU t"UM
ADDRESS: r. . <D ~)( (4).5 P~~~ C~CJ
CITY: ~ ~- J2....., /I I!/i !7f3tJGy,TATE: ~ /f ZIP: ::/ / ~ ';'7" q 7 4 c)
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BACKFLOV PER~#,IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
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CONTRACTOR: JI~~'k.""e:'T~Ai<:;~/I;;'3..f;, :.I' 2#~s~
ADDRESS: '2.>2AL ultYA.-~A;J ~AI# PHONE II: '7.JcPJ2/6-
CITY: Ih~/""- STATE: &.;{: ZIP: '77715'-7
CONSTRUCTION CONTRACTORS REGISTRATION II: J /,:;>? --;
, EXPIRES: l./~;Yd>-P(:;
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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SIgjiATURE
/67--(2-;;; .y
DATE
, FOR OFFICE USE
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DATE OF APPLICATION: / ()./ / z. - ~ 1 JOB ~: 9 q () ~ (-f 5
RECEIPT II:, n <'5 l(l.fO ISSUED BY: 17, fY)acJf~rJ)' (.)
TOTAL AMOUNT COLLECTED: !t; ,50
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