HomeMy WebLinkAboutPermit Backflow Test 1992-3-23
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
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Job Location: -:; .
Assessors l~ap II: //7(12
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Address: ""'1/9'?/ mA)N
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Tax Lot H:
0/50/
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Owner:
Phone H:
City:
State:
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Zip: '97'1 '7'7
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: G {2..A,NTS LA"Jk,C?fIf.? ~LAce-s IIvc.
Address: PO, tJ2;ox ~-;,..../
City: SIf??JN3-ue (d
Phone H:
State:
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Zip: O,)ij77
Expires: Q-9;;"
Construction Contractors Registration #:
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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Sign~re /
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FOR OFFICE USE
Date of Application: 3 -2 3 -'72-
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Receipt II:
I ssued By:
15,75
Job II: C?2{)cf<:, /
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Total Amount Collected: