HomeMy WebLinkAboutPermit Backflow Test 1995-5-11
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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
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JOB LOCATION: &,903, Fors''-'1ft'Ft-
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ASSESSORS MAP 1I: /6"O~ .c>~~Cit<.
OYNER: 5~ h~ 1 Qp.~he.'I(
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TAX LOT 1I: ~3 y~
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ADDRESS:
CITY:
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STATE:
PHONE 1I:
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ZIP: '171..(7)(
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: /)A.J-rt)J..)y 6t-uXs.
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ADDRESS: J7 ~<:" cl "'A-r-Ldt-i-.e.-z.
CITY: C, ~/L(nJC./~ /d
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CONSTRUCTION CONTRACTORS REGISTRATION 1I:
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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.
STATE:
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PHONE 1I: 7;) (,- 770 ~
ZIP: 97 Lf7 g
EXPIRES: LJ/?U/lro
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: . "5'-//"''9~ ~ JOB 1I:~CE;/~
RECEIPT 1I: 17~~5" . ISSUED BY: '/.r~ . .
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TOTAL AMOUNT COLLECTED: /6-.2~
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