HomeMy WebLinkAboutPermit Backflow Test 1994-2-10
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SPRINGFIELD .
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: I Cli9 VV"VA,,-,^ J ;::::"'4-J.
Assessors Map II: \1 ()L., 2, L.,4-") Tax Lot II: O~U.O()
Owner: <7 ()~fJJ/'l, 'frv:{Jqp.
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Address: \ Cj, <:; W\ ~ Phone II:
CitY:~)''^3.Q p O"j State: OR Zip: Cr'l'-rn
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:. tzu, hr. ^ rP (? p-;t;;,L'~ ~ .
Address: 9(') .~<"l-'<' rlJ'-IO{/O Phone II:
City: C;AAC,l~O State:
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Construction Contractors Registration II:
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Zip:
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Expires:
By signing this permitlapplication, 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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Signature
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FOR OFFICE USE
Receipt II:
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I ssued By:
Job II: C1 L/ () I c:; -;),
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Date of Application: d)I7)\"Iu
Total Amount Collected: $' It::, ,s