HomeMy WebLinkAboutPermit Backflow Test 1996-12-18
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BACKFLOV 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: 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:
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CITY: c:'/7!Z:f STATE: d
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CONSTRUCTION CONTRACTORS REGISTRATION II:~~
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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.
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/7-/4-"70
DATE
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FOR OFFICE USE
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TOTAL AMOUNT COLLECTED:
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::2 1097 ISSUED BY:
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JOB II:
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DATE OF APPLICATION:
RECEIPT II:
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