HomeMy WebLinkAboutPermit Backflow Test 1990-07-19E-
SP'TIil6btELD
BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97 477
Offi ce:
INSPECTION LINE:
726-3759
726-3769
CITY OF SPR"VGFIELD,OREGO'V
Job Locati on :LSnz AJ, tTb t?'
Assessors Map #:
Owner:
Address:
C'ity : State :
Backflow Permjt is $i5.00 + $0.75 State Surcharge
Tax Lot #:
Phone #:
Z1 o,Qf, V11
conrractor: TlmllW
Address:Phone #:
C'ity :State:Zi p:
Construction Contractors Registrat'ion #:Ex pires:
By signing this permit/app'lication, I agree to ca'll for an inspection once the
bac!f1gw prevention dev'ice has been installed and is vis'ible for inspection(726-3769). I also state that alI 'information on this appf icat'ion/permit iscorrect.
(P*, fuo tlQ.e"lt dSignature - 0
FOR OFFICE USE
a
Date of Application:
Receipt #:I 1-lL? o Issued By:
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Total Amount Collected:lr-?r
Job #:
6B
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