HomeMy WebLinkAboutPermit Backflow Test 1996-4-1
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY, DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
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JOB LOCATION;:: ~ ~.Y G4t~4~ L;? $?A"/' oR '17<17"K'
" ASSESSORS MAP ft:_' rJ ~A{ ) TAX LOT ft: OR.la')V
OVNER: 'Ike <<.'....r~r 1",,-,,- of- /J~'f ,.It 'Ctd.u< ",c4P
ADDRESS: "'6 I U q (-)..-1-<"""1 1..1' PHONE 1I: 7 'f( - 0 '1<)0
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OFFICE: 726-3759
INSPECTION LINE: 726-3769
CITY:
STATE:
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ZIP: 'J'74'7'f
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" BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
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PHONE 1I:
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ADDRESS:
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CITY: "5.0+ I ~
STATE: -:>L.
CONSTRUCTION CONTRACTORS REGISTRATION ti:
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ZIP: 7?~7~
EXPIRES: If I P 6
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.
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DATE' ,
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FOR OFFICE USE
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DATE OF APPLICATION: 4-. I,q~/J " I . ,JOBU: Q ~Olo02-.
RECEIPT #: /Jml() ISSUED BY: CC7xJ)() ') ,
TOTAL AMOUNT-C~LLECTED~ It 0 . t9f) VJ -
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