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HomeMy WebLinkAboutPermit Backflow Test 1994-2-10 '. . \ SPRINGFIELD . BACKFLOW PREVENTION OEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING. SAFETY DIVISION '. 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. o . .0 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: oJ 0 Construction Contractors Registration II: oP- q~ I ;;J I/O Zip: ClILfO";). SSb:'>lo,Lf 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. x't~\~~ Signature ::tl,o laL./ Uate FOR OFFICE USE Receipt II: II f.olL./ I ssued By: Job II: C1 L/ () I c:; -;), f;)~ Date of Application: d)I7)\"Iu Total Amount Collected: $' It::, ,s