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HomeMy WebLinkAboutPermit Backflow Test 1995-6-29 .. - .' ..'~~". 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: -z 7~ 6~h6" r~~ . K.z:> . . ASSESSORS MAP j1: /'/'0 ~~.z-z- Y 50" OVNER: Lc//D#7E'..?r ADDRESS: -;z '/70 0-'T/..../<!'" ~ /i.b PHONE j1: CITY: -5' .;t:>;<:,c...z::>.. STATE: t!9~. I" TAX LOT j1:~/,~ ~'Y')-~ - , ZIP: 9:./"7'/7 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CO~RACTOR: prc.rn- ~;tJnr- ? ~7f/~c=---; /;0'L , ADDRESS: -5'ZC:;- /f(e>~~ ~, PHONE j1: r:-~?-9/><'7/ CITY: &~~ STATE: ~. I ZIP:~~ CONSTRUCTION CONTRACTORS REGISTRATION j1: 6' 2€ii?7 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. .. Q .-7 T/ 7"7' NATURl 'I '7 ~ -Z-'??::? DATE FOR OFFICE USE DATE OF APPLICATION: b-~""7S" JOB j1: 7:-7cP'7c:::;-' RECEIPT j1: /??, /'Z~ ISSUED BY: ~~.. . //. -:>~ /: -- TOTAL AMOUNT COLLECTED: ~. ~ .