HomeMy WebLinkAboutPermit Backflow Test 1994-9-30
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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
JOB LOCATION: -9?":? .r,/9I":??t::e-~r ?L
ASSESSORS MAP #: /?~~--:YY'~2 TAX LOT #: ~.,::>gr?
OYNER:_.!.J7/3~~~ ",~ C.h~<-~
ADDRESS:
CITY:
PHONE #:
STATE:
ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:" q/C:;-f7:"/'~C- ?/?~~ ~6/~-c::
ADDRESS: ~C:;-~ s/7??~.....v-.J9j ~ _____HONE #: ?~') -?2::=>5
CITY: HL_1-" ~?,~ ~L:r STATE: ~ - ZIP: q:::>~.::5S~
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CONSTRUCTION CONTRACTORS REGISTRATION #:---.6~k EXPIRES: q,~~
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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SIGNATURE"
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1:'30
DATE
FOR OFFICE USE
DATE OF APPLICATION: q~:;-~..!'5' V
RECEIPT #: / Y-'7~'5
ISSUED BY:
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JOB #:
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49'rS'"/'V
TOTAL AMOUNT COLLECTED:
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