HomeMy WebLinkAboutPermit Backflow Test 2000-11-14
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SPRINGFIELD II
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: 113_~ (jj /ro Sc 11-.
" ASSESSORS MAP #:
OYNER: . cI.."'....c..--/...- /-J. -& S
ADDRESS: cr,~5 ~ ___,f 40(
CITY: .--. STATE:
;:-~e"'r
TAX LOT #:
PHONE #: 3q.S--13 "iJ
o..l?, ZIP: :771./0/
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR:
ADDRESS:
7:)LT
'ff/). I?O-L
~ k I.~ Ir ~'&:ua ~ ,E-n>..:o.-t:_
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79 I.JS 'IF PHONE #: 7 tlL{- 7(3":5
STATE: (JR, ZIP: "7 7$Lo I
t:, =? ~ 0 EXPIRES: 2-,12. ~ I
CITY:
,...-
..;- ......... ,
0/
CONSTRUCTION CONTRACTORS REGISTRATION #:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE
-J~
0'
1/ 111(/0 ()
DATE
FOR OFFICE USE
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DATE OF APPLICATION: 11- / L..J - )-.()lJl.J JOB j/: 00 eJ 0 G, 0 L.../ CJ (
RECEIPT j/: -~.fr.-37'i:>() ISSUED BY:' /l - (Yl a. cA-<ul v
TOTAL AMOUNT COLLECTED: !J /(1 so '
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