HomeMy WebLinkAboutPermit Backflow Test 1994-1-19
.
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
~
r
225 Fifth Street
Springfield, Oregon 97477
Offi ce: 726-3759
INSPECTION LINE: 726-3769
Job Location: /~~ (/(I~~'f/ e?-7.
Assessors Map U; / 7'7!P"7. 76 - 3"2
Owner: ~~A'-. ,?.h'h7/V}.j'';':''_<;'
Address: p....L? ,~A ?C/~
rr'-e=E~~
- - /
Tax Lot U; dJ<;;:>e:::>&:>
Phone U:
~w~~r
Zip:q? y.e:=>/
City:
State:
"
~?
"
Backflow Permit is $15.00 + $0.75 State Surcharge )( (
Contractor: /r~T~~ .~+--/nT~-~ -- .
Address: 3'$!?~~S-~~ qA1?c:?:? Phone 1/:
City: ~Pr::-LZ:> State: 67A.
,. , ,
72~ -o~.:2'::>
Zip: q,?y:/S
,J
Construction Contractors Registration 1/: -:a?~,I9~.P:;:9 Expires: /:<~~r-~Y
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 informatiDn on this applicatiDn/permit is
correct.
/-1/ _: J~
Uate
~~..-
, FOR OFFICE USE
Date of Application: /-/'9~"7'
Receipt 1/: //~5" Issued By:
Total AmDunt CDllected: /-5"': ~
Job 1/: ~ Y~~.>.:::.
~~8~ .
//"--