HomeMy WebLinkAboutPermit Backflow Test 1990-5-4
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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
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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-
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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