HomeMy WebLinkAboutPermit Backflow Test 1998-2-27
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
PHONE I:
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ZIP: q 7Lf TJ
STATE: (!)f(
BACKFLOY PERMIT IS $15.0).75~ erATE SURCHARGE) + $.45 (ADMIN. FEE) c $16.20
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CONTRACTOR: OX\. 'Ull -11,... IS' ..oS~ ..
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ADDRESS: 4" 041;t",~19~,co~ 0';).-...,
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CONSTRUCTION CONTRACTORS REGISTRATI~~: -fS4~ 1S'..o,co~ ~~, EXPIRES:
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CA~~~~N,INSPECTION ONCE TilE
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.
PHONE I:
CITY:
ZIP:
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7--- Z. 7-qfJ
DATE
FOR OFFICE USE
--------------------------------------~-------------------------------------~
DATE OF APPLICATION: ~. ~fJ.q 7\ J ~B 1I: Q <60~4 l
RECEIPT #:~q3\ - ISSUE~ BY: C\ljj) ) ,
TOTAL AMOUNT COLLE~TED: lto. nJ) --
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