HomeMy WebLinkAboutPermit Backflow Test 1996-6-26
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SPRINGFIELD
BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 ,INSPECTION LINE: 726-3769
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. JOB LOCATION: OY''){1,..,... J'1..,..!:, :.j~~~~E~ O~IJK sr."" .7J-J-d
. ASSESSORS MAP #: /703.;)..5 q I T.AX LOT #: 01 (J7) ')-... .
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OVNER: {l'jpp ~ OYU I~ (' ho d-d ~ us-v....
ADDRESS: 0lJld- &--I-7-L.J" 1)/2- PHONE #: ~2'f:; -71 LJ1
CITY: 5/J,,'''vy .ftelo! STATE:. De ZIP:
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: P""/~8fA Lav....t5ca~,'iA.n
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ADDRESS: 1'I:fO L~JC/~/(h.. .JJI/~
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CITY: /' U.&ld'P'N) STATE: a/2
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CONSTRUCTION CONTRACTORS REGISTRATION #: /.ll 7((')
PHONE #: 7 <y I - 6' d 'i' k
ZIP: "17<m~
.EXPIRES:~-:"h-C
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 ~ V
2tG<J t1vt/fh
DATE
FOR OFFICE USE
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DATE OF APPLICATION: G r).& - 7(,.:7 JOB #: CJ6/5tfS
RECEIPT #: eJ-::dd-.:;l3'4' ISSUED BY: /J. rYJc\inhadC)
TOTAL AMOUNT COLLECTED:.5I( 1(/7. )()
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