HomeMy WebLinkAboutPermit Backflow Test 1995-10-11
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BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING -SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: t..//A!) ~~~~~/C 7"
.' ASSESSORS MAP II: 1')-477_ "?C::::>...~ TAX LOT 1I:~~~1"tt:'<:,- <:"~
OIlNER: ~ ~t?f:s:t~~~ 7-1f:~/~
ADDRESS: -:'>~~,~~~c. ,:f?V. PHONE II: ~~~~/2?
CITY: e/~~-.E. STATE: ~;:o,. ZIP:
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
CONTRACTOR:.J2.;;rcrA' 4~L?~~ ?,:/~;t:;'/l'1; ?~~ .
ADDRESS: -::>2~C;- ,.~~~. PHONE II:~E-~/~
CITY: C~~ STATE:~' ZIP: ~/Vt:!!?y
CONSTRUCTION CONTRACTORS REGISTRATION II: 628'.> EXPIRES:/ <>..~- ~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
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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DATE
FOR OFFICE USE
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RECEIPT II: /~ 2'5''/
ISSUED BY:
JOB 1I:
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94i'-l10
DATE OF APPLICATION: /eP-//,~~
TOTAL AMOUNT COLLECTED:
/6. 7.t:>
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