HomeMy WebLinkAboutPermit Backflow Test 1998-9-18
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIE~D OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ct'Uq No-s..l H f2. I DAE
ASSESSORS' MAP 1I: '/ 7 0 ~ )..L; / .2
OWNER: )... A ~JQ.. 'J ~ A reo N I M>'
ADDRESS: <tOq ND~THR\OGE: ft~'j",,,2~ONElI: 74J-4DDO
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CITY:-'-s,2t:!.lNJ_' f::.1~Li) STATE: TI?)(SJ>Mw..."". ZIP:..:L7477
AUTHO"'7r.-D,-f' U'KL eXPIRE IF'rH<"
"." ./~.. UNDER' " <: WORK
BACKFLOW I'ERMIT IS $15.00 + $.75 (STATE SURCHfiRGE).CW:$f.Ml~DMW$_I'r_7~16~'20
,. ". ,,~ I'=' A8ANDO NOT
~ A.rrE:N ' "" ~~ v P,<"RlnD NED FOR
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IvOtifi . u'es a(i ''''!Jon /a
ADDRESS: _ in 0.4 ~~ion c",?.OPted b"."!: reqlli"'~ f.HONE 1I:
u090 ''''''<1-00 '-'. 1110 ''''vreg Vllto
CITY: _ ,,~,;. YOll 111"J' ~ZOIIS'NIJ.~~/~S 8,~n Util/tv
nu "'!JlI)ee lame JJ IIIR ~"'ITOrth
CONSTRUCT [ON CONTRACTORS R~e4 O!Jl^~Ples Of tb~ 952-00. EXPIRES:
. Center is ~~:~on U~i,;;e~e'~~;'~~: by
BY SIGNING THIS PERMIT/APPLICATION, I A~-l'~:vBk'efs;l~ AN INSPECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED ~ IS V1SIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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TAX LOT 1I: J;) / '-I
CONTRACTOR:
ZIP:
'" V!:71 n u L1 M~~
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q~{<{, - q<[
DATE
FOR OFFICE USE
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DATE OF APPLICATION: . 1 r . JC$ 1I: q 1/ 02S
RECEIPT I: ()_~/f./I ISSUED BY: j. th ~'
TOTAL AMOUNT COLLECTED: <t /Ir Lf)
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