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HomeMy WebLinkAboutPermit Backflow Test 1997-11-4 . . BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD .:1{/t1a..J....:1J-I. ~ BUILDING SAFETY DIVISION 225 FIFTH STREET e;~ ~Ih'St..:c, OFFICE: 726-3759 SPRINGFIELD OR 97477 ~ INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: 00 (6' ~ ~ , ASSESSORS MAP It: t")OO(')()t"', /"")()n("")("")r"') C") "..:7' ) h...- T....A~ T'J I~~ .-..... .5 TAX LOT It: O\lNER: ADDRESS: CITY: Sj:?;f'.~,~..{"~~4 <9A. PHONE #: STATE: I.#A; 7'ttl- ?.tcc ZIP: 9'7 Y7? BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 ... . CONTRACTOR: Uw..-Al/";.A LA'~~"n;4' ADDRESS: CITY: 2r.::l.-:t? //-< -I..... {;f. J'~.4..... ~,fA,/ 2..,,/ PHONE #: STATE: .O.}J8. I I ir7 ;J.. 13o-.?? ,.r ZIP: 9''7 et'8'? EXPIRES: 1../- St?'-'J 9'" CONSTRUCTION CONTRACTORS REGISTRATION It: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO\l PREVENTION DEVICE IlI\~ BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769), I ALSO STATE T~~~:NFORMATION ON TillS PERMIT/APPLICATION IS CORRECT. rHIS . AurH;ERMlr SHAl.l. ' ~ Co RIlED UNO EXPIRE IF ~ 7d:E~CEDORIS~Ro~HISPER:~E.WORk /1- ~/-7 /7 SIGN rooE' .n "'ERl ~; .1,uONo IS NOr DATE 7' 00, DFOR. FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: I-( AJ~hv.- RECEIPT It: .:275 () ,d.27~sSUED BY: ~ TOTAL AMOUNT COLLECTED: i>l lIJ ,d- 0 JOB It: 0,7 J5~ ( ----------~--------------------------------------------------------------------- ;1