HomeMy WebLinkAboutPermit Backflow Test 2000-2-24
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.
SPRINGFIELD
707
00
.50
CHANGE:
CASHIER: 001
BACKFLOY PREVENTIO~ 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: I L-b CtJ trJ ~ Pn. f2-1I I l("W P(Z.....1 If 'f:- .
. ASSESSORS MAP #: 1"1 ('j '3 Z- 7 '3 I
OIlNER: JIl..-l-- f-tb'i ~ (..--A---
.
ADDRESS: /1-3.G W fAt ,e..1I1 WJ Dr2--1 (((...
CITY: <;;;('K-ll\I&f\ ~LO
TAX LOT #:11LIO ~
STATE: 0 K-
PHONE #: 7 '2..-" -}< 67 g--
W: <'Jg'l-470(P'
ZIP: "'It '-f 7'1
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR:
Sf6'--r
ADDRESS:
PHONE #:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AG~EE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS
CORRECT. .
""V~~
'2-- ~l/-(} 0
DATE
FOR OFFICE USE
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DATE OF APPLICATION: :;;r/)..cfj (J7) JOB #: (}()()OOOsoJ
RECEIPT #: 1m. ISSUED BY: IJ . fYJa(}M du
TOTAL AMOUNT COLLECTED: .JJ; / D, so
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