HomeMy WebLinkAboutPermit Backflow Test 1995-7-18
rl
.
SPRUtlELD
~~
.'
BACKFLOW 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: 80S w, Ol~""r\',- st S'rfcA
" ASSESSORS MAP 1I: /-7t? ~ 2. 7 ~ 2- TAX LOT 1I:
OWNER: .::ro. VY\e.s L. H A"", /1-t\:>"::' (
i
ADDRESS: ~(J.s; \.1J, Ok. "'-nl'" $1,
. I
CITY: -.SO f ~
,
9'/411
C:>/D/f
STATE:
PHONE 1I:
OR-
J<t7- SIB 9
ZIP: '11'(7/
I '
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS: "5iJ~ "'~
O\.r'V\ev
(.l \'<;i" \
PHONE 1I:
CITY:
STATE:
ZIP:
.~ONSTRUCTION CONTRACTORS REGISTRATION 1I:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. . ,A1~ ~ &Ii ~ar f- 5,6-0_
S'o?" Jf,r.,c. ~ _
}"J# ~/.u. s;~o
~ d.. ~L-+- 'rJ ~ I ca~ '7S
SIGNATU~' \~ DATE
FOR OFFICE USE
DATE OF APPLICATION: 7//fB /7J '
RECEIPT 1I: /<;:1; 3' ~~ "( (ISSUED BY:
JOB 1I: Q5'/2(Yl')
/;A-, , . /
TOTAL AMOUNT COLLECTED:
/&:,2.0
------------------------- --------------------------------~-----------------
'?j/8(fS- ;F /~3S'7 fT5",'f"'O ~
~2..{!d A "A:f4/d4 ;A)<~ (1Io,)~ &-~)