HomeMy WebLinkAboutPermit Backflow Test 1999-3-23
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIE::.D OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726..3769
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JOB LOCATION: 12:1 I
. ASSESSORS MAP ft: / -10_31 J, l/ Lj
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OVNER: S~i/A"J-<- Ct9~1 ~';;;;;:'/'J" .'
ADDRESS: ). 7q tj J- R(} n SOh r M .
CITY: f:-;()..[JOnL-- ..::.-.-
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h[\DONED FOR
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PHONE #:
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ZIP: 91V~
STATE:
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 l~~WN~OFE~) a $16.20
on laW "I on UtIli f
l>-i\e:N\\ON'.Ole~d b,/ t",e Ole~le se\ lort"'.
CONTRA,CTO!'j: )/u.^,7L~ T.A'...eM{?"'J!Jes~.J"'~ep,l~~~,
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ADDRESS: ;)..".J;J.:/.. ~ S7?f'J9o-</4:4'AY~11~52.001.0, .~Jil.QNRli'll-"j ~.~:J' ':U.r-
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CITY: }/:."'....../,. O~1i~.;t\'rtl~~I~.,.nn\Jtl\IW~~, ZIP: 9~?I"'8'?
, ca I betlOltn" ~1' 800.33'"'''''' ...-
CONSTRUCTION CONTRACTORS REGISTRATION ft: n).ll)'~? p..~.\eris . EXPIRES: 1-3 6' ~)' :P
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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DATE
FOR OFFICE USE
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DATE OF ';PPLICATION: ,~J2.3lqq .IJ JOll H: 9~(fltv
RECEIPT t': ()33b'-;-: ISSUED BY: ;:;, 1YiJ))/\.-
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TOTAL AMOUNT COLLECTED:
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