HomeMy WebLinkAboutPermit Backflow Test 1998-4-12
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING ~AFETY DIVISION
225 FIFTH 'STREET
SPRINGFIE:~D OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 9)'7 ",u;? n&AJ,.;/A'.z:)
ASSESSORS MAP #:' / /!J:) L3>Lf.3 TAX LOT #: d-3 0 0
OVNER: '';:;;'',,,,A-<. P J-/,p~~.<',
ADDRESS: .f, n. I!-,o)( 7 L/ 2 ~ PHONE #: 7LJ(j- Jjl'/0 0
CITY: {~iJ~ - STATE: f)1L ZIP: 97r/o (
BACKFLOII I'ERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: .1./1L~'<'/? T,,{'~/<Jo,4-r;;.v J /&......c::7sc~ J?....<=-.
ADDRESS:_,.;26-:::z..:tC ..s77f'.t...-6:,."pA'v 1A"'.~ PHONE #: 9J..r~'J.2/,~
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CITY: 1/'<.~....:r-4 STATE: '9JJowr;Jih<7'if}N:OregOn.JaJJIP: 97'rS-7
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CONSTRUCTION CONTRACTORS REGISTRATION #:-L./ jrI.0~Ot~genter. ~re~;t~:;;;
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, calii ou may Obtai rO~9h OAR 9 Set fOrth
BY SIGNING THIS PERMIT/APPLICATION, I AGREE To~n~<AHJte&'I!Gilfom:' ~g~1-
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND \1!J:~~ R e.E1ItsP1il1J, s by
(726-3769). I ALSO STATE THAT ALL INFORMATION ON T tp~~I ~~
CORRECT. 2'2344). On
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$,/-/.2- <79
DATE
FOR OFFICE USE
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/ __ ~JOB #: C;f/2,sC)
- ISSUED BY: If. 11/;~_
~/rA -M -
RECEIPT 1':
TOTAL AMOUNT COLLECTED:
l . -,