HomeMy WebLinkAboutPermit Backflow Test 1999-11-22
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SPRINGFIELD
BACKFLOV PREVENTIO~ 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: /Gd'5' ,P~~C~~ ?~"J:f.f'tv~1r c~r
.' ASSESSORS HAP II: /?d>~'2,tt;2'? TAX LOT II: ~ ~)
OIlNER: r~~~ .(#C.
ADDRESS: C!9C7.:::Pf>W-.1f~#~~v#'27#' PHONE 1I~
CITY: ~AE ,.(/-?I~&:;t7 STATE:~?,
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ZIP: 92?3e:"
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURfJlARGE) + $.45 (ADMIN. FEE) c $16.50
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CONTRACTOR: I..~~ ~~/AV<S7/...,...-_0/&/-
ADDRESS: .' ~ ./.? fi-AfY Q ~ ::> PHONE II:
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CONSTRUCTION CONTRACTORS REGISTRATION II: / /2-?"?c!:J
CITY:
STATE:
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C:;Y/~~/,,;)~Z9?/Y
ZIP: 9')~
, EXPIRES:
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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SIGNATURE
FOR OFFICE USE
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DATE OF APPLICATION: //-2?~q9
RECEIPT II: --=3',.;;;?;::;2 ISSUED BY:
TOTAL AMOUNT COLLECTED: --:2 2. d>"Z5
JOB II: 99.6 999
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