HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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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:
ASSESSORS MAP ft:
941-, 'nrv_~~~'
1'7~"::3-:2"'-'; -c:;>~ :rAX LOT ft: O~'3
OYNER: Future B
Hom~F;
.PHONE ft: 4R'i_11"'16
ADDRESS: 1'icn Ri vpr pni nt-P .f)r
CITY: Eugene
STATE:
oregon
'ZIP: 97408
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20
CONTRACTOR: Hunter Irriqation & Landscapinq
PIIONE ft: 935-3215
ADDRESS: BOX 454
ZIP: Q74Rj
,EXPIRES: L.{ 30 'f,b.
CITY: "~r:Jw~", STATE: nr~'J~n
CONSTRUCTION CONTRACTORS REGISTRATION U: 11372
BY SIGNING TillS 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 TlllS PERMIT/APPLICATION IS
CORRECT.
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'e"fUG .- .1\ . ~
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DATI> C v
FOR OFFICE USE
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TOTAL AMOUNT COLLECTED: I~ ,,,,6>
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