HomeMy WebLinkAboutPermit Backflow Test 1993-9-27
r/
.
.
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location: 71) 9~- J1 o~ S'}:-
Assessors l~ap #: II 02 <..,c:::;, 2,4
Owner: }{, "..j <: /'J ){;..",
Address: 709<'- fu,'.y, ,)-r Phone #:
City: rtunj f,e./o! State: Off
Tax Lot #: ()1~'2.,J I
*
Zip:~7 '17 L
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: e YnfJ ra lei b...11 Y1//,r,1'1 of'
. /
/'1 CI tl1 eu/<; If 01
Address: 3'i Y 8" J
City: EVjenp
Construction Contractors
State:
Of?
Phone #: 7'17- 59'1(,
Zip :..:l.L'I 0 5
Expires: 7-? / - '1'/
Reg i s trat ion #: fa:l \? I
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 .
S kh-v1 (J_1AA'~'7/
Signature (! (/
9-17-9?
TI'ate
FOR OFFICE USE
Date of Application:
&] J"n 10,,,,
Job #:
C) 2., 1'-1 } '>]
Receipt II:
JO'-/oY
Issued By:
G06
Tota 1 Amount Collected: ~ I c., ,/~