HomeMy WebLinkAboutPermit Backflow Test 1995-5-30
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SPRINGFIELD
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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. ASSESSORS MAP *: /6~2~t::'4-4>C:a
OWNER: ~Jf'~/~~4#~.::::r~
ADDRESS: 73 y';;'p .i?t1'~... J ~. PHONE *:
CITY: ~P~vZ::>_ STATE: /:2 ;~'.
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JOB LOCATION:
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TAX LOT *: ~~;~
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ZIP: q;J 7?g-
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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PHONE *:
CONTRACTOR:
ADDRESS:
CITY:
STATE:
/
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION *:
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
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5r-3()~ 15
DATE
FOR OFFICE USE
RECEIPT *: /7 "5'~ 7"
TOTAL AMOUNT COLLECTED:
ISSUED BY:
JOB 1I: -95'~,/:::>
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DATE OF APPLICATION: ..,-- ':/t:'- ~