HomeMy WebLinkAboutPermit Backflow Test 1991-10-17
.
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: ...-::? ~ t70 t"'?~o//'hP/c 5r.
Assessors Hap If: 17~n2-"30-e:>~, Tax Lot H: O/"'T-:<B
Owner: E~~#C2/ #Y2;)P.A'VL.../e::.S
Address: 3,-/2.2 C/c.. ~,..,..P/C Phone H: 7't"7~:z/~
City: 0/?r-U? State: C:::S;:;>. Zip: 07"-1:?fit
I'
Backflow Permit is $15.00 + $0.75 State Surcharge ~~~
Contractor:
,4') fpf'/E/?
Address:
Phone H:
City:
State:
Zip:
Construction Contractors Registration H:
Expires:
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.
SiO,tff ~~
~/f/
FOR OFFICE USE
Receipt II: "2/6:zc:::l
Total Amount Collected:
Issued By:
Job H: q/09~ 3
.~~~~
Date of Application: /L>-/7-9/
--:? / _ -5?::>