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HomeMy WebLinkAboutPermit Backflow Test 1996-12-18 . - BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 ------------------------------------------------------------------~------------- JOB LOCATION: qqD. dr/On:.),J KJ ~//);fq;-7'7/ .' ASSESSORS MAP II: . 1703J.jo01)/(;:;<, TA~ LOT/II: O\INER: ' .f::.J, ,f'/>/ ,/'2, ,/.;./.""""'<:.. ADDRESS: :2.,c;q~ -:-Qlvw -bnln1-e...., D PHONE II: ~/4'<~ 3//6 CITY: n5t/lrJJ- STATE: O~ 'zIP:Q7tfr;s- BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: c;~)./{ ~ /-~i..'JI ,~ ADDRESS: Ldn'<9<n /Y2 t.~,; .1.1-,,>/ PHONE II: f! . /. . / CITY: c:'/7!Z:f STATE: d , i CONSTRUCTION CONTRACTORS REGISTRATION II:~~ . . /' 7'ijij' 7/.5..s ZIP: 97o/?7< EXPIRES:~-c;r~ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. ~J4"- /7-/4-"70 DATE , ,. FOR OFFICE USE -------------------------------------------------------------------------------- TOTAL AMOUNT COLLECTED: . I;}- {@; ~q(/? ::2 1097 ISSUED BY: lfo -an 11/ t JOB II: q h()yOc.j DATE OF APPLICATION: RECEIPT II: --------------------------------------------------------------------------------