HomeMy WebLinkAboutPermit Backflow Test 1994-7-27
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SPRINCFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
Job Location: S'8q"2.- ('nfH,J A1;
Assessors Map II: /'7/97. :5 L'I ') /-
Owner: Srn..jf- Roh, ',vc;
Address: 37SS- E!W\OoJ..J crt
City: PtJ_l\gN-IL' State:
U
Office: 726-3759. ~
l'SPECTI0' LI", 72'-37'9.~
Tax Lot H: D/) <)/ i)
225 Fifth Street
Springfield, Oregon 97477
Phone H: 687-BI(s7
o e Zip: cr7lb3
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
r0'!l)~'c; ~cf'j-
Address: P.D. AI\Y: Z2-1 Phone H:
City: ~[").J~-he(ca State: ~A2.
Constru'ition Contractors Registration H: S~L
7z(irSJ34
Zip: 9ffl/
Expires: IO~Qf
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.
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h~ ,f\VVVJA
Signature ~
7-27'--94
uate
FOR OFFICE USE
Total Amount Collected:
/6'. '2'0
Job H: 947)@0S-
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Date of Application: 7-?;>-"cr.
Receipt II: / Vb -9? Issued By: