HomeMy WebLinkAboutPermit Backflow Test 1999-2-8
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SPRINCFIE.l.D
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIE::,D OR 97477
OFFICE: 726-3759
INSPECTION I:INE: 726--3769
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JOB LOCATION: 9' t:l 7
.' ASSESSORS MAP II: / -{ 0 ~
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TAX LOT II: L/~
OYNER: Fu:ruj..,
ADDRESS: PO. 80 Y...
CITY: h1J~
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $t6.20
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ZIP: ...9... 7.c/C::J!
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CONT~O!'j: ./.,/ u..".;77CA' .rA',e"i~7I::"/ fi' .lJ'1"'~S~TImf:'~on law reguires vou 10
,- .A'^"","; . . follow rules a~~~~ed by the Oregon UtilIty
ADDRESSII'!.~. r :J J It: S'77f:? ....~A'rfv' .IF-~, """-- Nntifil!!l~dbl ~~=..i?,U';;;;; ~ot fmth
TH/SPERWTS . inGAR952-001-00tOth~(~lha.~Ot-
CITY: y.z ^ ~XPIR1= It: Tu.- '''-r . STATE: &~n v_.. --l'~am.;;tl W by
AU I nUH/ZED UNn1=R - .. v, or, . .
CON~'l)RUCTION CONTRlC:ToR'S'FREGIST)y.;rION II: -LI J' ~ ...c;all"ng ~he cengtp~~,.:~;;::~l)pD.9,9
- """C'~vtU OR IS ABANDQ 2.<__. .61 tl.~ regontill v....v~..vn
Ar'Y 1 " ',' PFRI()f1 NED FOR Center is t -800-332-2344).
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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DATE OF I;PPLICATION:...o..1 7(/ q 7
RECEIPT I: 03;). If (; 7 ISSUED BY:
TOTAL AMOUNT COLLECTED: (Ii / & ' d )
JOB U:
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