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HomeMy WebLinkAboutPermit Backflow Test 2000-11-14 . . 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 -------------------------------------------------------------------------------- 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) = $16.20 . n. . CONTRACTOR: ADDRESS: 7:)LT 'ff/). I?O-L ~ k I.~ Ir ~'&:ua ~ ,E-n>..:o.-t:_ I V' 79 I.JS 'IF PHONE #: 7 tlL{- 7(3":5 STATE: (JR, ZIP: "7 7$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. N--- SIGNATURE -J~ 0' 1/ 111(/0 () DATE FOR OFFICE USE --,----------------------------------------------------------------------------- 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 ' --------------------------------------------------------------------------------