HomeMy WebLinkAboutPermit Backflow Test 1996-6-19
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SPRINGFIELD
BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: q;(q j1/ut/' Kuj/ ,
" ASSESSORS HAP 1I:~""3.:;r~...~
OVNER: 'hsLe.- /< -I-hc
ADDRESS: ?~7' %~;~~~ lJ~. PHONE #:
&e:;;..~ STATE: ~,
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TAX LOT #: .....,.I..-~
CITY:
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ZIP:.7'/.y~
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ->c;/4L~:s' L~c.vJ~r
ADDRESS: '-7"0(,'60 Me..--.Je/J~'; .JL~/ PHONE #:
CITY: c:;oJ'L/ ST:TE: 6/J
CONSTRUCTION CONTRACTORS REGISTRATION #: ~ .c..(' 3
ZIP: '91/7?9,
EXPIRES: .::?-~'7 7
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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6- /? '76'
DATE
FOR OFFICE USE
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DATE OF APPLICATION: ~~~~
RECEIPT #: 22/0<.> ISSUED BY:
TOTAL AMOUNT COLLECTED:
/6- <C>
JOB #: ~~?.:L.
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