HomeMy WebLinkAboutPermit Backflow Test 1996-7-15
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BACKFLOY 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: ~6S-..b Lt?L~.Ao?~C. ~,
, ASSESSORS MAP #:. J~'3-:2..,...41/ TAX LOT jj: ~C>O
OYNER: .~~1/.7~ '~~__7:> )?~.;_ ry~! '-~
ADDRESS: /2~"3"'::? (k/F' ~~y~. PHONE #: '2"5'5""'~"':f
CITY: ?~~<I.~Z> . STATE: ~ ' ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
CONTRACTOR: ;7f~k='; -I' ,~/~ 6
ADDRESS: ?~n- ~:..:'~___-?' /~~
CITY: 6~~;:E STATE:
PHONE jj;
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ZIP: ~~
EXPIRES: /"'- 3/- ~
CONSTRUCTION CONTRACTORS REGISTRATION jj:
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77
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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'~RE J/
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DATE
\t J1vJ_AA J"ft FOR OFFICE USE
~iA <!~__J~L~~________________________________________________________
DATE OF APPLICATION: 7-/:::;.....9,C JOB j\: ~~'
RECEIPT #; :2ZLA?:z.... ISSUED BY: ~.-?.........' -. . .
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TOTAL AMOUNT COLLECTED:
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