HomeMy WebLinkAboutPermit Backflow Test 2000-9-12
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SPRINGFIELD
BACKFLOV 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: \ '2.c'7. VE.L KCl'::f. ot,
.' ASSESSORS MAP l!:
TAX LOT l!:
OVNER: '6lZe 6 I;-t~-)
ADDRESS: 12C, 2.. \}€:L- ~SE.
CITY: 6(J~\N6 f:\IZLQ
flJOT/Cj::. PHONE l!:
S~~~~E~~SHAI/ .-,,~ ZIP: i:n4-17
"V I HUI1ILEO UNO ~.,.,. '''1:: IFTHE~
COMMENrr=,., . ERTHISPFP," '_ aRk
BACKFLOII PERMIT IS $15.00 + 1. 05 (STATEI\SURCHARGE-)A+'? ,$:,'{+54/(ADMIN!ITFEE')) = $16.50
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CONTRACTOR: VI N.Th6.r. lAN.\)S(Mlf G l>E.S>\bN. LLC
ADDRESS: v. a - Gu.,L \~ ~v'3 PHONE l!: ~ I. - \SS'\
CITY:~ ~~~ STA!,E: Or;2. ZIP: ~744a
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CONSTRUCTION CONTRACTORS REGISTRATION lI;!ifj..~...J~e~lidn~d" "4u~IMS: ~ 0 I
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BY SIGNING THIS PERMIT/APPLICATION, I !ILlD0as:~' 1~6Rr~h~.. 6wtONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN IN 'mme~ srv4sIt~L!lf ~CTION
(726-3769). I ALSO STATE THAT ALL INF ~hW6t ~l1!Eaffiritf. ~MJ:.ucI.:'rION IS
CORRECT. . Center is 1.6g8 on Utility NotJ. o~e
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: ~/ Fd/09 JOB l!: (}O~OI3 f:f 3-01
RECEIPT #: ISSUED BY: 5E -I
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TOTAL AMOUNT COLLECTED: (") A;: rM 55
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