HomeMy WebLinkAboutPermit Backflow Test 1999-10-12
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BACKFLOV PREVENTIO~ 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:
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AUTHORIZED UNDER THIS PERMIT IS NOT
PH~~~~~91~1~~~~NEDFOR
19,;(. ZIP: 9''7''7 7~ $?l7Io j.
.' ASSESSORS HAP II: J'7 ()3
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OVNER: . k"-;:"'~ rf'~' J./,........... ~
ADDRESS: f O. JjO)(. 7~)'5
CITY: ,.::j?R? _' ~(.o, f!utn3\,..J6 STATE:
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BACKFi:olicPERI:lIt:tS.' $15.00'0+'1.05 ,(STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50
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CONTRACTO~:~ ',': /.J;"~'( r'::-f. Ttf&!3'..t:~.., .e -I ~~.c:JS ~j?-<- r-vc.
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ADDRESS: :2~.s-A.U 6'j-/i?9;:'~A'Y' ),~/. PHONE II: '1:7,,-.1,3,./.r-
CITY: V-c."'.....r-;fJ... .<7/ STATE: ",,{'E_ ZIP:.1.7Y'&''/
CONSTRUCTION CONTRACTORS REGISTRATION II: J I ,7? 2.
. EXPIRES: 7'-.7,,-.QD
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. '
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DATE /
FOR OFFICE USE
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DATE OF APPLICATION: )0..../2...... 71
RECEIPT II: D 35 l( LfO ISSUED BY: f) .
TOTAL AMOUNT COLLECTED$ / f.., ,50
. JOB II: qq0477
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