HomeMy WebLinkAboutPermit Backflow Test 1996-9-11
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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: 1077 (JE:t.+uuat! 11----:>
ASSESSORS MAP !I: 17 O~.:?7 -7 ^ I
OYNER: 'fuAvM VI ~~ J-1~A'L....
ADDRESS: ,[07'7 r~,+VA '%.2u l.p --
CITY: ~ri ~\-h\O tel I STATE: f)p
BACKFLOY- :ERMIT 'r-sJ$15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN.
CONTRACTOR: ~VtA-1 yBrL~,_ c..o
ADDRESS::2.' f
CITY: 6C\~ _ STATE: 8~
CONSTRUCTIorA:ONTRACTORS REGISTRATION !I: (:)0077
TAX LOT !I: 6 -:J ~(J e-,I
PHONE #:
ZIP:t(7Lf/;
FEE) = $16.20
PHONE !I:
71//&rt ~2 I
ZIP: Cf7t.tD2.
EXPIRES: 1(') - :<;/- q ~
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.
V,' ~ J?~" ~~tp~~~ k4
C'~ r' v /'
9'-/(-7&
FOR OFFICE USE
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DATE OF APPLICATION:
RECEIPT #: 2. ~ I L-( (1., ISSUED BY:
TOTAL AMOUNT COLLECTED:_~ L0 .2()
9-t1-'1eo
111/
JOB 1I:!lk.J 23 L{
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