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HomeMy WebLinkAboutPermit Plumbing 1990-4-25 J~ ,. BACKFLOW PREVENTION OEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILOING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: '7b~1 (7/a (J(Y DriVL Assessors Map #: Tax Lot #: Owner: 1aI11lJlC, ~ t {};mrw-1" (f)//in5 Address:-7 IJ-37 (1/(lc(if ()-riLlL- City: <fJr1(}c..fi{)tl State: az Phone #: ziP:Q7t.j 7 g J Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: ~dcL ~d-s~ Address: -5LffY I maJizWf eeL Phone #: City: ~ ~0f./1L State: Af:- .c,.,,.,C"+'''II-;+';^"l- 4:-:-...,J.-~..t~ J Regi-J.o:.-f-..! -- ~ ~~ 'iJWJ~"~'~" . 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 application/permit is correct . 1;,p;-Cf;;'/t, Expires: ~~ Signature - ./, %~AA J '1/::J.5/fO Uate r ~, FOR OFFICE USE Issued By: Ie:;, 15 Job #: /IIlJliJlYIil q()(j{;;D / Date of Application: , . Receipt #:~Y3 J Total Amount Collected: l/ J)-5' /q/) /