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Home My WebLink AboutPermit Backflow Test 1994-12-20 -. . ~ SPRINGFIELD BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING, SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 .'~ Office: 726-3759, INSPECTION LINE: 726-3769 Job Location: 341 < (~('r, !;../ Assessors Map II: /'7~ 2. ? I' ~ / Owner: fV)~i k L..- A"'" "4;,00 r /'1a/' - srt~~ /'lR Tax Lot II: FJ?'7ht2....- . . ~~jj Address: Phone II: 7,26 -7b 7<!J City: ~. State: Zip: Backflow Pennit is $15.00 + $0.75 State Surcharge -r o..{5 ~,..<:J. ~ contractor\:-b"C)', j!~ L~_LC1/)' a_oIz;.;.,..,!.,;' 7/.r, '\ u Address: t../6..c~0 Mc..~~,~- d..-...," Phone #: 74'.1-/-7/.3.< .- -CCJ+!../ State: c>A7. J ....J '. Construction,Contractors Registration II: /2/70 ~ ,~ ~ City: Zip: 9'7 L.,/ 7'7< 0'1(/1 t: Expires: ::.. By signing this permit/application, I agree to call for an inspection once the backflow preveiftion:-device h'?s been installed and is visible for inspection (726-3769). I also,~tate that all information on this application/permit is correct. '. ..-:-~~~ ,~'f4. - -iJ "/ ,.,. /I A A A " i ____- S1gnd, - - - /J ,':""~,.; . ."~~ /:< h71 Date' , FOR OFFICE" USE Date of Application: !'~~~~~~ Receipt #: /<;;PrtJ! Issued By: Job 1I:~!3~ ~ ",d ' I -, 4f Total Amount Collected: It::. '2.0