HomeMy WebLinkAboutPermit Backflow Test 1999-2-4
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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
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JOB LOCATION: to lr (, '2. P:. r<, ft",,< sf-.
ASSESSORS MAP fi: \ 'I. () J- n:s. \ 1 no ";1-K'l) TAX LOT fi:
OIINER: T,' """ P ~ fk~.~
;gENT, IQNf,,~~t>law reSUlres you. ~v
ADDR1ro; - .:k>l vthefOaagqnp!'!ilY s:h PHONE fi: 71.f1l- 9Z 50
T61 0\. ,.~I~- nt Those rules a{e-selfallll NOTICE: .'
CIT~!l~:~~~~-~~.<tv.hm"~n OAR 952-001- STATE: 012.. .. n_ .._ ~.... I 'Zl',!Ip,: I/:'Tr.!ClI\\"!)RK
0090. You may obtai~~~\]Pi~~~~~::;~~~~ by ~~~:O~:;~~ ~~~-;R- THIS PERMIT IS NOT
BACKFkQl\1I,$l\,u'1"I~r.~D t l'dNtlti(i~a~$ifATE SURCHARGE) + $.45 (ADMIN. FEE)"~o$16'r20R
numberlorthe Oregon I 'Y COMI"WNl;; U uH IS "o-:",~ ".~"" ~
CenteriU-800-;332.~344). ,." '_'" ~"p.~:'")
CONTRACTOR: i:>v~< 1{4... :s L.,..l5~v< --I- r~V','),f."'~
ADDRESS:
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PHONE fi: rJ/-L/,- -1('35
CITY:
STATE:
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ZIP: 97<1-7'1
EXPIRES: <... /....'1' In
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CONSTRUCTION CONTRACTORS REGISTRATION fi:
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIllS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE
dJdev
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2../ <fir 1
DATE
FOR OFFICE USE
- DATE OF APPLICATION: ";).-4 ~Cj c;-
RECEIPT U: n.3 )..--;1< 7 ISSUED BY:
TOTAL AMOUN~ COLLECTED:. \t \ L? _ ;ro."
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