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HomeMy WebLinkAboutPermit Backflow Test 1996-7-15 . . 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; 7P~ '/hZ./ ZIP: ~~ EXPIRES: /"'- 3/- ~ CONSTRUCTION CONTRACTORS REGISTRATION jj: ~. 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. ' /1M - : 2'.' , 4.--- -' JJ.6-.?. , '~RE J/ 7""r-r~ 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: ~.-?.........' -. . . y/, TOTAL AMOUNT COLLECTED: /b. ::us -------------------------------------------------------------------------------- (