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HomeMy WebLinkAboutPermit Backflow Test 1990-10-3 . BACKFLOW PREVENTION OEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759. INSPECTION LINE: 726-3769 Job Location: 0LtC:; t?duJYLOlllt--' Assessors r~ap II: \n()~~I-3 Owner: / A) 111lJA Ism; H, Address: t;1/JZ:;'T~ 1J)1JM City: r;,1d. '-" St~e: f)L Tax Lot H: er1nCorD ' Phone H: 1J}u 'Stft/t} Zip: tJ1W ..." Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: ti ~ Q Qi\\ 0 ru\-- \\ t t \\~~ X"Uv Smo~ . . Address: ,6lo0~\ 0Ilro~ 0) r }f ct J\J Phone H:.14icrQ()C{q_ . City:~rt/ State: (Qfj ziP:ql41~-q7B3 ~~1'.e;~gi't"ti;" I, ':'-,5-"\c:--. "pi"" 102,\ flO . 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 . . ."'h"//A~ ~~gLo _ slgh':fure {/ J /0 - -;; - 9G:> Date FOR OFFICE USE Date of APPlication:_'(O. o,qO J;...,#, .Job H: Receipt II: /f)4{l& Issued By:C/\Lm .J Tota 1 Amount Collected: \ (~), f\ ~ q{)l~l~