HomeMy WebLinkAboutPermit Backflow Test 1999-6-11
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SPRIIJGFIELD
BACKPLOII PREVENTION DEVICE PERMIT APPLICA'GON
CITY OP SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTTON LINE: 726-3769
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JOB LOCATION: tfo7?' ~~ k':.,<> {L
ASSESSORS MAP II: /7 ('13 ? ~ 4 3> 6 407; C) TAX LOT jl:
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OIlNER: J--.....I.....~ c.- ,-!:Pt-...-..s
ADD~~::~UII~~~~'~~'-~~;;~_~~, PH1>liE !!: 7 q c...; - :;(,? tI 0
Notifica)Kl~vemel. lIiJ~e\L,d~~,---... ' ~ulICE: ' , .
C~'Fit;A~2AnO~~~ughOAR 952-0?," STATE: (~P.e8MrI.SI-lAII FX~~J~~ /
0090 You mal obtain copies UI U Ie I lUO.:J lJ J 0'"
irn the blnter. (Note: the telephone AUTHORIZED UNDER THIS PERMm N I
BAC~tt%lJ.~g~"'kTo~I$-l!illioq. ~+Otltl9-!iC(STATE SURCHARGEl::GMSAe'll!CErJl~lSAlIlllt,j~ONED FOR
CentE" is 1-R(l(l-332-?344). ANY 180 DAY PERIOD.
CONTRACTOR:_I-Iu.~,~A' J-.A'.ftr,n...., -Il#_,d."i'tO~-.... ~"'c_
ADDRESS: :J.. ,~..... :1-.:t C J'77f'",-, /ff!./~o/ L oJ PHONE ,Ii: ~r.r..,;>2..I,f-
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STATE: to/?
CITY:
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ZIP: '?'7"1S--'"
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CONSTRUCTION CONTRACTORS REGISTRATION 1I:~? 7 ::L
____EXPIRES: Y-V-".-o
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....,. BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIIlU.: FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PER:,!) 'l'/APPLICATION IS
CORRECT.
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DATE
POR OPPICI! USE
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RECEIPT II:. ()3 5/7;( ISSUED BY: 17, ma {I ha. d.(j
TOTAL AMOUNT COLLECTED::8 / {;;", so
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