HomeMy WebLinkAboutPermit Backflow Test 1996-4-5
.
.
DACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFElTY"DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
JOB LOCATION:
<1lfo ~~
lA)~
,rAx<1>T #: ~~~
" ASSESSORS MAP \I: /'":?r1?3-;2~~
OIlNER: Future B Hm"<>"
ADDRESS:--35,91 R;VPT p'nint-<> nr
CITY: Eugene
PIIONE #: 4R"_11"76
STATE:
Oregon
'lIP:
97408
DACKFLOII PERMIT IS $15.00 + $.~5 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: Hunter Irriqation & Landscaping
ADDRESS: 1'\0" 4'>4
.PIIONE #:, 935-3215
CITY: uonof-? STATE: ()ro']nn
CONSTRUCTION CONTRACTORS REGISTRATION #: 11372
ZIP:~
' ?XPIRES:~
DY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
DACKFLOV PREVENTION DEVICE liAS DEEN INSTALLED AND IS VISIDLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT,
~
nG~A'lU
~ ~ ~ L-/:/7--~
DATE' ,
--------------------------------------------------------------------------------
DATE OF APPLICATION: f~c::. /:Z-JOB11: 9~..:>9
RECEIPT #: ?;t-f10& ,ISSUED BY: L./~Y""L
"
TOTAL AMOUNT COLLECTED: /~.~
FOR OFFICE USE
--------------------------------------------------------------------------------
'-