HomeMy WebLinkAboutPermit Backflow Test 1989-12-28
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SPRIFIELD
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:
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Assessop ~ap II: Tax Lot II:
Owner: ~ t t\ \ '\\Jl ,\~ ~~)
Address: ?-K) ~ \ \ ffi (\ \-(')\ \ \~ Phone II: i\ ~~-C\ \" \n
City, f \ ~ I\ 0 . st.t" (lh 0 T' z;" C\I'\"\() \
Backf10w Permit is $15.00 + $0.75 State Surcharge
Contractor: ~}." \. .v. ~r)'\'('\ \. ~\ \. ~f\\.t) \~
Address: Phone II:
City: cr J-.. Joe.f\ L State: CJJ.J\ oC[)(\ Zip:
Construction Contr~tors Registration II: 4\q ~ \ ~ Expires:
By signing this permit/application, I agree to call for an inspection once the
backf10w prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct.
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Signatur~ I .
/P -..2P-?'l
Uate
FOR OFFICE USE
Date of Application: g),!J R . S:,C-1 , pJo~ II: , SQXJ\ ()~M'
Receipt II: /\.~I..o~~ Issued By: t1)lJY) _ '>
Total Amount Collected: I~.\)~ ' '
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