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HomeMy WebLinkAboutPermit Backflow Test 1996-4-5 . . 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: 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. \'ll~~'-'_.'\~ ~\\.~. A 'e"fUG .- .1\ . ~ L//2-) qJ. DATI> C v FOR OFFICE USE ::::.:::::~~;~~:;;::::-:--~,1~~~--------:::;;;~:::-:;:;:;:.;:::::- TOTAL AMOUNT COLLECTED: I~ ,,,,6> -------------------------------------------------------------------------------- J