HomeMy WebLinkAboutPermit Backflow Test 1998-10-2
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 FIFTH STREET OFFICE: 726-3759
~:~:~~~:~I~ILq~rq~..9~~W ..requires Y~~~-----------_:~~~ei[~~~:~~~--~:~=:~~~THE WORK
- follow rules a~op.te Y VI ~V" t f rth THIS PERMIT SHALL EXPIRE Ir
JOB LOCAlJ!ooWiation CE!ll.lefl1:hos rare e. ~ _" i7"" IIMnl=R THIS PERMIT IS NOT
in DAM >lO""VV '" b ,.--- R
. ASSESSORGOBIiP:411; tf(\' ~~;~1-:~~fl~~~~~? Y TAX ~WIMf:Nt<EP~~DONED FO
OWNER: . ~~o~~t~<<?.ryUtilily,NOlification. otN 1~O f)~Y prRIOn
ADDRESS:. q \) ~enter(jr~t';r"'C-:- PHONE #: -
CITY: ~Y-'J+;.I!rJ STATE: (ire. ZIP:
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: Lu' {.4J5~ ~"'VI~fS
ADDRESS: )<{ I ('320~ ~Ii-t
CITY: E lNV.~ Q1 STATE:
CONSTRUCTION CgNTRACTORS REGISTRATION #: Lei};
PHONE #:
'3\1<(-- "1032.
ZIP: Cf7VfJS-
EXPIRES:~~
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INS:?ECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. .
SIGNATURE".
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DATE \
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FOR OFFICE USE
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DATE OF APPLICATION: I. D /' )- --CJ. >(
RECEIPT h ns/040 ISSUED BY: () .
TOTAL AMOUNT COLLECTED~~ \ (1).60
JOB #: Gj)(astO
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