HomeMy WebLinkAboutPermit Backflow Test 1992-8-24
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SPRINGFIELD
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELO
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location: fl}vfJ oCet< QL\l:\?--
Assessors f~ap H: 170 <' 2- 2- S I
Tax Lot U: /d 70-0
Address:
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state:
?hone U: 7q / - ? 5~h
()fJ2.- Zip: 91'477
Owner:
City:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: u)\fJ\OfL WV}(JV?l2-
Address: 1/10 LA- Kv__ 'f)/l,
City:~ ~ UC State: (/o/p
Construction Contractors Registration U: 5" I '3 0
Phone U: pJ'l -0'11--<-(
Zip: 17107
EXPires5Blff --=f
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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
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Sy.inature
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Date
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FOR OFFICE USE
Date of Application: g - 2--1- '7 2-
Receipt II: 5''772- Issued By:
Job U: 9':2-1173
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Total Amount Collected:
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