HomeMy WebLinkAboutPermit Backflow Test 1996-9-11
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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
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JOB LOCATION: ~ ~~/ ~~~/?7~/~
ASSESSORS MAP D: p"fl!?2 -7I1!'!J- 0/3
OYNER: ~~-,tV'- {C}-#f
ADDRESS: ~~~/ ~/ Y.r6:z?r ~.
CITY: -5P..r::L.Z; STATE:
~.
TAX LOT D: ~/~
PHONE II: 7 ~':::::'&!>62'7
~. ZIP: &:3'/0$
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CITY:
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7,7/'7 /~/~&=?" U~ ~ PHONE D:
~C/.::::;.cr~C STATE:?P/lf.
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ZIP: q/~'3
EXPIRES: /I!'!J- '3'/. 9~
CONTRACTOR:
ADDRESS:
CONSTRUCTION CONTRACTORS REGISTRATION II: ~~~~ ? ?
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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1l7J~//-96
iJAft
FOR OFFICE USE
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DATE OF APPLICATION: "7-//- ~
RECEIPT D: "2~ /7"'3 ISSUED BY:
TOTAL AMOUNT COLLECTED:
/L.'::>~
JOB II: <96/Z7'~
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