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Home My WebLink AboutPermit Backflow Test 1998-2-11 . . BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATIO~ CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH ~7REET SPRI~GFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 JOB LOCATION: 90S- J?// <,f )(:1 b L~ .' ASSESSORS MAP #: O\INER: J:U-/l.I.;f-e. TAX LOT #: ./ ~" /? ffl--<- '" ADDRESS: CITY: S/,#~!~L~ PHONE#: 7o/</-~C6e; STATE: ..o/F ZIP: ~7Y77 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 _ ' /J 1v,k . . CONTRACTOR: ),Iu~r"</f' TA'~~A9~"'):'~,,;/ /"'NL)SC";P-<"" c.r- ~ ~ y. ADDRESS: :J.. .,j..:<:t.c ..)/~t&~\~)~/" PHONE #:3 ?.r-:-.1';:Z/~ )C/ .('~.~ .. c.ll CITY: v::: __c ~ ( ,.</ 'f.? ~ Q... <? rST~J: <9 ~ ,ZIP: '7 '7 ~?'7 .'. ~ 'Jb ( . CONSTRUCTION CONTRACTORS REGISTRA;{~ ~Yf ~/~ 'J . EXPIRES: (/-.7t9,.....<7~ ~Q-?&~~ . V 't ~ ~ BY SIGNING THIS PERMIT/APPLICATION, I AGRE~g~~OR AN INSPECTION ONCE THE BACKFLOV PREVENTIO~ DEVICE HAS BEEN INSTALLE ~S'~cf.~IBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATIO ~ ~~ERMIT/APPLICATION IS CORRECT. 01' V,.. ~ ;;k- SJ.cfiiiATURE .7~/)-/!r DATE FOR OFFICE USE DATE OF APPLICATION: .!1- 1/- '7 t RECEIPT #: :10 0 & ~ ISSUED BY: TOTAL AMOUNT COLLECTED: dP J In, dO JOB II: OJ 7 j?yC; <-I ~) , , .