Loading...
HomeMy WebLinkAboutSpecial Inspection Fire Department Referral 4-7-12 BACKFLOW PREVENTION DEVICE PERMIT APPLICATION. '" . CITY OF SPRINGFIELD BUILDING. SAFETY DIVISION 225 Fifth Street . Spr i ngfi.e 1 d, ,Oregon 97477 Office: 726-3759. INS~ECTION lINE: .726~3769 Job Location: j L.j 6J ~ (JJ -no . s ,LJ fr/:',e;--P,'<.L rGJ Assessors Map #: Owner: ;/AlkP,HgA/ ;(1,5-e-!9- ..., . Tax Lot #: Address: '2 ~IO V CJ I/o City: -S~;f}~rq ~ ;~)"LJ Phone fI: State: tt),f/E Zip: Backflow Permit is $15.00 + $0.75 State Surcharge Contractor:. f/I.LN~~~~,;34-r/~ "',,- Address: K& ~~ ~.r-'/ Phone II: 9 S J'- '3' ~ IJ- City: z/...e..,...c-<::7J.1- State: 6'J1'f: J;:3'J2 Zip: ~?ytr7 Expires: d- r-J ~ -<7'( ....) Construction Contractors Registration #: 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/permtt is correct. U//L SiWh~ure 7-1'::< -' ;7 y Uate FOR OFFICE USE Total Amount Collected: 7//2-/7d I I Issued By: /6 ~A{) Job. #:" 9+103 '7 ~ Date of Application: Receipt II: /3~~ r