HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOY PREVENTION 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:
9 4~. ~ ~ ~)"c1\A".\.~Q ---
TAX LOT II: cJ1/~ ~
ASSESSORS MAP II: /?-?S-=3 ."'2":3~
OYNER:.Future 8 ~omes
ADDRESS:--1.5.91 Ri IIPr pni ....t-<, nr
CITY: Eugene
.PHONE II: 4R<;-3176
ZIP: 97408
STATE:
Oregon
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCIIARGE) + $.45 (ADMIN. FEE) 0 $16.20
CONTRACTOR: Hunter IrriC'ation & Landscapinq
PIIONE II :_935-3215
ADDRESS: Rnx 4<;4
CITY: ','_ --:-':i. STATE: nrD'Jnn
CONSTRUCTION CONTRACTORS REGISTRATION U:. 11372
ZIP:~
, .EXPIRES:~i.
BY SIGNING TillS PERMIT lAP PLICATION , I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
~
1-/- ! 2-lll~
DATl:1
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FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
{/s(70
ISSUED BY:
/ &.2,0
~ JOBU: q~ /?t::''7-
, ~'..
.,., .. I '
DATE OF APPLICATION:
RECEIPT II: "'2.bJ '7? 0
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