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HomeMy WebLinkAboutPermit Backflow Test 1996-6-19 '- . . 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 -------------------------~--------~------------------------------------------- JOB LOCATION: q;(q j1/ut/' Kuj/ , " ASSESSORS HAP 1I:~""3.:;r~...~ OVNER: 'hsLe.- /< -I-hc ADDRESS: ?~7' %~;~~~ lJ~. PHONE #: &e:;;..~ STATE: ~, , , TAX LOT #: .....,.I..-~ CITY: ~~~/~ 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. ,dd~ L.l~ 6- /? '76' DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: ~~~~ RECEIPT #: 22/0<.> ISSUED BY: TOTAL AMOUNT COLLECTED: /6- <C> JOB #: ~~?.:L. 7~~' --------------------------------------------------------------------------------