HomeMy WebLinkAboutPermit Backflow Test 1996-7-26
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SPRINGFIELD
BACKFLOW 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: ::(2.. ~5 S. ~",hw~h ~\l.
, ASSESSORS MAP 1I: ~ /~/)Z (0 h /2... TAX LOT 1I: ~. ,')2.0~
OWNER: OA,j /)ZI (~4.8' ,
ADDRESS: ~7_~~ S. R.af)W<>ol) /)/L
CITY: ,<; fJrlJ STATE:
PHONE 1I: '?7.h-'I'1'l2
Ol'f..... ZIP:_97 '178
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: ~ t. M &. f\. S. ~p-\)\J E.
ADDRESS:
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PHONE 1I: " :',
CITY:
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ZIP: \, , ~
EXPIRES:~
CONSTRUCTION CONTRACTORS REGISTRATION 1I:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOW 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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FOR OFFICE USE
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DATE OF APPLICATION: t/ /2-6 h A
RECEIPT 1I: '2'1-(" c){ ~SSUED BY:
TOTAL AMOUNT COLLECTED: ~;;~ ~
/J JOB 1I: 9;:; / /!)20
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