HomeMy WebLinkAboutPermit Backflow Test 1997-4-19
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SPRINGFIELD
BACKFLOV PREVENTION 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: 717 EAm71?6o
.' ASSESSORS MAP l!: J 70 S ,<.;t' /."?
OIINER: . 7i ""^-- "" ~/~ Olh6C-V
ADDRESS: 797 ~IJ~
CITY: s,PJ<,.w::> STATE:
TAX LOT l!:
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PHONE 1I:
rilL-
ZIP:
91<M
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
CONTRACTOR: {!LAs~/C- {.PNOSCAPef,.,
ADDRESS: 'P.O. ~I<: foWl
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PHONE II:
, 72(p - 0-/3. </
97VO I
CITY: Ev;. STATE: (9 ~ ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION 1I:L2pd~~fw.J:. {AC #~7-9>XPlRES:
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.
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SIGNATURE
,~~J7
DATi:; "
FOR OFFICE USE
DATE OF APPLICATION: j 1)7,;.f. 7
f1l /
RECEIPT It: :2 ,.-gc;Q ISSUED BY:
TOTAL AMOUNT COLLECTED: /~ .2.1D
~OB II: c; 7~571
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