HomeMy WebLinkAboutPermit Backflow Test 1990-3-14
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BACKFLOW PREVENTION DEVICE 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:
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Assessors Map #: / 1- [)~- 3f...r -3 I
Owner: .feu,,; fiL N w be II
Address: / li /3 tY/aj/} SrfYe.tj.--
[;pfcJ, .' State: !)fl.
Tax Lot II:
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Phone #: .
Backflow Permit is $15.00 + $0.75 State Surcharge
Zip: Q71'l1
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City:
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City: W/ldtJ- State: ()I{ ziP:31J..jJ>~
Construction Contractors Registration #: ;)2'-;)'Or;.f4xpires: ?ifff-. 3tJ" /q1{)
Address:
Phone #:
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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.
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Slgnaiure I
3 -/7"~ 90
bate
FOR OFFICE USE
Date of Application: !3~ /f-q'D
Receipt II: 16 ;}-ft} Issued By:
Total Amount Collected: ~}. ~()
Job II: C(OD3D ~
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