HomeMy WebLinkAboutPermit Backflow Test 1998-2-17
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BACKFLOI/ PREVENTION DEVICE PERMIT APPLICATIO:i
CITY OF SPRINGFIELD
,BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIE::.D OR 97477
JFFICE: 726-3759
INSPECTICI LINE: 726..3769
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JOB LOCATION: 9t?o M~X::J ..7/"::'
" ASSESSORS MAP I: 170 3231.f i
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.TAX LOT tSSO 0
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Ol/NER: 'f-.t<-"7;;.~~ ;?" J-/~ ,......-c. -S
law requires you IV .
ADDRESS: _' ATTENTION:Oreg~n...i..lhf' Oreaon l!t!I~Y~. J'H9NE I:
_<;>~ follow rUles dUv,I.-- -, e rules are set!\\IITI,...E. .
CITY: J FlM5-+? -o;,{;m:lr.ation Center. ~h~~:.~WPi\ll9~~c~m C::~A' I ~l(P'f~IIf:THE WORK
952 UUI-VV'V r..._.'9 lesoy.
in O~R OU ~ay obtain copi~S of th: r~T#iORIZED UNDER THIS PERMIT IS NOT
BACKFLOI/ PERMIT IS ~~~lIRR:lfth$ ce!iotE(lS1!'tgo:rei_&~,r~d5J ~:.(I.P!S,E.l'!3A:ll!lg')JE-!') $Ol~. 20
. b rfor the re 344)
num e C ri51-800-332-2 . A~'" -'J,'/ Fi'R'I):)
CONTRApTO!';: f-/ '-<--..-'/<.-<' ~ A"~<;"" /'4'" .,E / ;9~/dS'c:_r>-<..
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ADDRESS: ~ ,r-.J....2. C S?-A"";O.....&.A"..,?y .) A-v-c. .PHONE I:. /J..r-3:2./.r
CITY: JA /,,~/?',1 STATE: (!)% ZIP: '}P'Vcr?'
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CONSTRUCTION CONTRACTORS REGISTRATION I: J /. f? :J..
EXPIRES: -!:L-J't1J - ,j1
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN:;PECTION ONCE TilE
BACKFLOI/ PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE i:JR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT, APPLICATION IS
CORRECT.
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FOR OFFICE USE
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RECEIPT I': ~3~' I ISSUED DY: 11. h/J,/ 1...-._ -_
TOTAL AMOUNT COLLECTED: .~ / (f . J-{")
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