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HomeMy WebLinkAboutPermit Backflow Test 1997-4-22 . . 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 -------------------------------------------------------------------------------- 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. 7~ Y-'J.. 'l.- ~ 7 DATE FOR OFFICE USE --------------------------r-----l-----------------------------------~----------- 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 -------------------------------------------------------------------------------- ~ . '. - .~~~ : @ -(twP0 ,. ~