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HomeMy WebLinkAboutPermit Backflow Test 1990-5-4 I' . .~ SPRIN~FIELD 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: 2-35'=i mwtll sf- Assessors Map II: J 7 D ?3& L/ J Owner: f1~' Jfi1./J?f1- /2-os h/)y() Address: 2';50'1 fnu" VI Sf- City: Spy) Yl~ -h'.f.lc) Tax Lot 1I:!,)7~'2,Cl0 Uum he, V " Phone II: 7 L/ ~ S>4 J I Zip: qr '-177 State: ()'1L Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: SCL PILt~h"/16' , Address: 'iiRZ/jJr --r-8VVI-/nV /0./ I2d Suh...3 Phone II: City: V.e,I/IP.Jc:t State: 1'JT2- Construction Contractors Registration II: b(') - Zi}/ P-€> Expires: '1 hfJ 5767:1 . Z -10-9/ 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. 137 -2/5fo Zip: Q71./37- ,4.! R,--enJk 5=---1 -?PJ Uate FOR OFFICE USE Date of Application: t:;-4 -t:;[) Job II: CfooC}L/Cj Receipt 1I:JM!}.0 Issued By: ~ Total Amount Collected: $/1],1.0