HomeMy WebLinkAboutPermit Backflow Test 1998-5-7
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225, FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: 12Sb ~OG,or~~.
, ASSESSORS MAP ll: I -;. 0 ') 2, 1) c..f
OVNER: I?IIUA> bs.J V. I ~()~ ~.~ w -'
ADDRESS: 12 ~~ ~t.ub~ ~a-.
CITY: ~t'lIU'~tsr::b
TAX LOT ll: 02..t 0 7,
STATE:
PHONE ll:
8-f2-.
ZIP: ~.,.,...
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE~ = $16.20
CONTRACTOR:~ ~~rlO'
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ADDRESS: 2..TL UI~,,".tpc.......u ~
CITY: ~~
CONSTRUCTION CONTRACTORS REGISTRATION ll:
PHONE ll: 48S--05"~'
STATE:~' ZIP:~
~/8oq EXPIRES: I//i'/~
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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 INKORHAtIQN ON THIS PERMIT/APPLICATION IS
CORRECT. ' '1lV IIl,;t: .'
THIS PERMIT SHALL
AlJrHORIZ~D Uf\lDE EXPIRE IF THE WORK '
- ;~~~;~3~ED OR IS ~;:~~~~~';~: ~/1. /?g
"-.;" t"r:HIOD, bATB' '/ 'I
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S JNATURE
FOR OFFICE USE
DATE OF APPLICATION:
s-hhr
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O?- 97- f?-
ISSUED BY:
JOB ll: 9'i ()5''-I1
alwJ
RECEIPT ll:
TOTAL AMOUNT COLLECTED:
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