HomeMy WebLinkAboutPermit Backflow Test 1996-4-26
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING.SAFETY-DIVISION
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225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 10 Cl c.. ~ .g O.J.../J
" ASSESSORS MAP ft: J 70 J 2..) &0
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TAX LOT ft: C)/eo3
OVNER: ('N C\.-li ~ '\ 0 O~OLJ"o---
ADDRESS: )t;) () (~ r,),O l'IIUl..tO-T\& L....."
CITY: "5 r ~ > 'no '" r:: I ,I rO STATE: ()~
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
PHONE ft:,?'/ ?-O/5'
ZIP: t:t? Y 77
CONTRACTOR:
ADDRESS:
CITY:
(90 A,}!3P2
.-r~K
PHONE ft:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION ft:
EXPIRES:
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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SIGNATURE
Lj ,- ),.() - 9"
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FOR OFFICE USE
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DATE OF APPLICATION: #0(~ /-..
RECEIPT ft: 2/3tJ+ ISSUED BY:
TOTAL AMOUNT COLLECTED: / (;; ?-o
JOB 'tI: 9C:;rJ~f3,2
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