HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION
225 FIFTII STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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ASSESSORS MAP #: 1?--/)-::jr"7,~-v'd:5
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~TAX LOT Il:
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JOB LOCATION:
OVNER: Future F HomeR
PHONE I: 4R<;- ~176
ADDRESS: ~<;q~ Rivpr pnin!'<> nr
CITY: Eugene
STATE:
Oregon
ZIP: 97408
BACKFLO\1 PERMIT IS $15,00 + $.75 (STATE SURCIIARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: Hunter IrriC'ation & Landscaping
ADDRESS: Rnx 4 <;~,
,PIIONE U:, 935-3215
CITY:~~>-~, STATE: nr~?~n
CONSTRUCTION CONTRACTORS REGISTRATION U: 11372
,ZIP: q74R7
,EXPIRES: t..f ISlJ/q(,;,
BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLO\1 PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT,
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DATE
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FOR OFFICE USE
DATE OF APPLICATION:
RECEIPT #: _ '/._//'/-" ~
TOTAL AMOUNT COLLECTED:
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ISSUED BY:
3/,2.0
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