HomeMy WebLinkAboutPermit Backflow Test 1990-10-3
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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:
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Phone H:
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Zip: tJ1W
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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 .
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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\ ~
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