HomeMy WebLinkAboutPermit Backflow Test 1995-10-4
.
.,
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
--------------------------------------------------------------------------------
JOB LOCATION: Y-9./C? &R5'?T#~.4 A
. ASSESSORS MAP 1I: /A'-cr< ~t:/-d(? TAX LOT 1I: ~2<3:;.-c;...>
OVNER: . Z?~ ~~/? ~~ ...
/ ,} - . .'.... . - &'
ADDRESS: PHONE 1I:
CITY:
STATE:
ZIP:
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:Z/YV/~4~r..4C t;-f?~~~r!r /./.~~C~~~
ADDRESS: h// .#~ ?c?~~,. PHONE 1I: . ?c;.':) - ;g~-<. ~
CITY: ~ STATE: ~ . ZIP: ~V;:>s.
~. / - . .
CONSTRUCTION CONTRACTORS REGISTRATION II: S~ ? EXPIRES: ?,-3,.. "7~
//:Is~ \
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. .
t/
FOR OFFICE USE
"
--------------------------------------------------------------------------------
DATE OF APPLICATION: ~? ~ '?s
. r
RECEIPT 1I: /9/90::;;::: ISSUED BY:
TOTAL AMOUNT COLLECTED:
/6. ::2e::>
JOB 1I: 95"~/YS-
4~'
--------------------------------------------------------------------------------