Loading...
HomeMy WebLinkAboutPermit Backflow Test 1994-7-27 . . 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. )\ h~ ,f\VVVJA Signature ~ 7-27'--94 uate FOR OFFICE USE Total Amount Collected: /6'. '2'0 Job H: 947)@0S- /?~'- // ' Date of Application: 7-?;>-"cr. Receipt II: / Vb -9? Issued By: