HomeMy WebLinkAboutPermit Backflow Test 1997-4-22
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BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
I <-:
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 9"2f R i',fttV Km'Ji/I/2/1
, ASSESSORS MAP II: 176~ 1'3,00 ~ TAX LOT #: / {)o....<,
OIlNER: r, <I-f,/i/fl /'7, 11mw,..8
. · ADDRESS: ~Sq?, '~i V 1/ Pninr-€- /)(/'v.,(" PHO~E U: '-I~S -3/ 7 V '
CITY: ' P;11~.lh/ STATE: Vf/L ZIP:Qj4{J'6
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: )-/...._..T~
ADDRESS: p;fJ L,yo' $fl,s-S"
CITY: J/c,,~,.+
-:IX' /? .q/)//.,..- ~ L~~I,(7SC/4/,""-
.PHONE U: 93.r:- '$:Ur
STATE: ~/f'.
ZIP:
,EXPIRES: Y-J',,-7r
CONSTRUCTION CONTRACTORS REGISTRATION #: II J' "1-
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
'CORRECT.
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Y-'J.. 'l.- ~ 7
DATE
FOR OFFICE USE
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DATE OF APPLICATION: 4/ JJ-- q r JQB II: 07 oS 't 7
RECEIPT 1I: () 2 S L{ ! I ISSUED BY: i ~V 111; ,()~
TOTAL AMOUNT COLLECTED: 1; 1(/..) 0
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