HomeMy WebLinkAboutPermit Backflow Test 1995-7-24
v -
-
BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: 5712.. ~rphA
. ASSESSORS MAP 1I: /~/"} Z. 61- //
OIINER: Je:r-7Jcs //hi!
ADDRESS?t J'~2. ,}, 5"1'b g... 5 r
TAX LOT 1I: A 0 /.2-c::>
CITY:
~~
- . ~
STATE:
PHONE 1I: 7~7- J 17.J
~ . ZIP:. 5' 7~9:!t,
BACKFLOV PERMIT IS $15.00 + $,75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
C>tf..),V~
ADDRESS:
PHONE 1I:
CITY:
STATE:
ZIP:
.~ONSTRUCTION CONTRACTORS REGISTRATION 1I:
EXPIRES:
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, ,
;04~.r
DATE' '(.
FOR OFFICE USE
DATE OF APPLICATION:~~~~~~
RECEIPT 1I: /fb424 ISSUED BY:
TOTAL AMOUNT COLLECTED: J {;. ?..O
JOB 1I: 9+. 1/70
~~.
'-
--------------------------------------------------------------------------------