HomeMy WebLinkAboutPermit Backflow Test 2000-5-30 (2)
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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
JOB LOCATION: 55 Lj {b / r() tJ t) sf,
.' ASSESSORS MAP l!: /7b?~ C/ ~ '"3
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OlmER: Gerard T d tArO! I+ta:l'koWlJll't e
ADDR~is: 557 Po ( 'hl'v 4 .sf.
CITY: S iJr,'",...-Pr '",rc! STATE: otR.
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TAX LOT l!: CJr:;:>~
PHONE l!: _q€~~~~
ZIP: 971.("1?
BACKFLOW PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~$16.50
CONTRACTOR: ~1{;P'~
ADDRESS: PHONE l!:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION l!:
EXPIRES:
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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SIGNATURE
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DATE' I
FOR OFFICE USE
DATE OF APPLICATION: ~.... ~e:>~~
RECEIPT l!: ,,~/~~/ ISSUED BY:
TOTAL AMOUNT COLLECTED: / b. ~
JOB l!: ~d'b6"Jr.> --I'
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