HomeMy WebLinkAboutPermit Backflow Test 1994-10-10
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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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JOB LOCATION: _'1' 0 0 F ~AllrLA4 S' ,(1/"0 ,'-.-.dI, luJ;...,I
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. ASS~SSORS MAP I: /?"/J ~ "$ 4 2-2- TAX LOT I: O;;)<fii!,."$-s!
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ADDRESS: JO 0 &.~ "ff~ PHONE I: cO 'f'f- 'I b / l/
CITY: SD~p-,J (J STATE: (')IT ZIP: 97'177
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: e yYj 0/1 A J",/ ;;/ ~AU'~
ADDRESS: -.:L'-I fr r;- I M a A~ R,.,/ PHONE I:
CITY: e..IA......I /YI j STATE: (() 11
CONSTRUCTIO~ CONTRACTORS REGISTRATION I: (,.,:J. ~ /
1'17- S <?yt,
ZIP:.JL'f 0 ~
EXPIRES: \('-? /- 'I')
BY SIGNING THIS PERMIT/APPLICATION, I AGREE 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.
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DATE
FOR OFFICE USE
DATE OF APPLICATION: /t?//~~?~ JOB I: 9110470
RECEIPT I: IS/)/2 ISSUED BY: .('.?IXt,
TOTAL AMOUNT COLLECTED: / t:? ~