HomeMy WebLinkAboutPermit Backflow Test 1998-4-27
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SPRINGFIELD .1
BACKFLOV 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:
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TAX LOT #:~(()
, ASSESSORS MAP #:
OVNER: ' p, I II R PERt; U,C;IJN'
ADDRESS: 51? OJ F.o/?c:;yTHiA DR
CITY: E PR INt: ~;ELJ) STATE:
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PHONE #: 7Lt7- q73/?
n R ZIP: q 7471
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: -..S A A!'./: _ A ,<; )I b t:J V 11 ,\r: 1AI0P.\I.
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ADDRESS: I', _...~1I'" S~~ll -'1<' rCQlJ.1'T IS" PHONE #:
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CITY: ,L....I.lOP.I'lEOU t" 'Qll.NOO!'l~AT1:: ZIP:
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CONSTRUCTION CONT~~~~~ION #:, EXPIRES:
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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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FOR OFFICE USE
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DATE OF APPLICATION: 4;:27- 9~ JOB #Q~LJ4~l
RECEIPT #: !;(\n~) ISSUED BY: n ' fYlf)(lJrfY,/{'.
TOTAL AMOUNT COL~ECT~D: l J/ / &, dO