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HomeMy WebLinkAboutPermit Backflow Test 1998-10-2 ., ,-' -. .' SPRINGFIELD BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION ',/ 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:~~ (Jt< ~7q~ 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". J /l.,fM \[)-~ \ ~\" 91 DATE \ I FOR OFFICE USE ---------.----------------------------------------------------------------------- , I I I I I, i"--.. DATE OF APPLICATION: I. D /' )- --CJ. >( RECEIPT h ns/040 ISSUED BY: () . TOTAL AMOUNT COLLECTED~~ \ (1).60 JOB #: Gj)(astO dYla cPr.-a..(L <. ) --------------------------------------------------------------------------------