HomeMy WebLinkAboutPermit Backflow Test 1999-10-6
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISIO~
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: .~()3(J hFflEJA)A!L L(),~ SnIN('1I-Ii::;L\;--' Cf7<.f11
. ASSESSORS MAP II: J 7 03 d-d- ''7r1J TAX LOT I: O,~ SCD")
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OIINER: h'1n"\) INI1'J~IKII":--' t'J>..i"-",,T UNION
ADDRESS: ~O~() -GATI-c~JA(1 Ln~
CITY: '::J '\->R \ N hFi l=:C ~ STATE:
PHONE I: J L/ I-:J f,n.<:::
ri\2... ZIP: 914//
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B~lP:J\l.Jd'6ilW8h18 Sl,~. 0 +- ~'''/5 (STATE SURCHAR~~) t+. $.45 JADIHN-,w FEE)rl'" '$16'";20
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ADDRESS: iSS' CL~trnli~.rnJj;-I),:'R LANe __"._ PHONE)I: "Jr/,D';-c""l0,,~,
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CITY: S ?i<..1 N r-.(:: I eLf-..... STATE: 111J"(~ '1'..0 2'?: ~:.~;I~I~:~:i~i1-'7 >(
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..cONSTRUCTION CONTRACTORS REGISTRATION I: Lc..:f'-, ~ hi.., qs:- , - EX~~RES: ~/ Jr)()OO
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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S'~A~RE
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FOR OFFICE USE
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RECEIPT I: 03579:"..5 ISSUED BY(\ machad CJ -
TOTAL AMOUNT COLLECTED a I (() ,5()
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