Johnson, Jess .
T H E � G i T Y � O F
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BACKFLOW REGISTRATION FORM
Registration is for one year from the date of registratian or re-registration.
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Mailing Address: t ���P �C�-��C� S'�"re�-`� ����" �+`� Na-� , ► 7�- � � � ��
(Street&NumberJPO Box,City,State and Zip)
Physicai Address: �`1 D�- Ir-cund�mcu' k-- Co u.,Y�-, ���r�,�u� `�� `��c�
(Street&Number,City,State and Zip)
Office Phone Number: � (�� � C � - a > l �
Mabile Phone Number: � �� � � �d - � �J �
E-mail Address: `�SS �'� ��S S S ar1 n �L.�fX S , C,4 ✓�'1
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City of Cappeii Public Works Dept.
816 S. Coppell Road
Coppell,TX 75019
972-462-5150
www.coppellUc.gov
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BILLING CONTACT
Jess Johnston III • �
Jess Sprinkler Installation & Repair �` •�
6805 Inwood Drive �
North Richland Hills, Tx 76182 i
INVOICE NUMBER INVOICE DATE INVOICE DUE DATE INVOICE STATUS INVOICE DESCRIPTION
INV-00011729 09/10/2018 09/10/2018 Paid In Full NONE
REFERENCE NUMBER FEE NAME TOTAL
Misc Fee Backflow Contractor Registration $75.00
SUB TOTAL $75.00
REMITTANCE INFORMATION TOTAL $75.00
City Of Coppell
P.O. Box 9478
Coppell, TX 75019
September 24,2018 255 Parkway Boulevard, Coppell Texas 75019 Page 1 of 1
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