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HomeMy WebLinkAboutPermit Backflow Test 1993-6-30 -- . I. ., BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELO BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759. INSPECTION LINE: 726-3769 Job Location: 0J 1 ~Cvi (w cL0 {J J, #:(i~3~.. [\)(\ttwVTax Lot #: O\r3(;~ . Address: C1;;r1 :r!l1(~4:M fl. ~l~d . Assessors r~ap Owner: ~.t\e-... Phone #: 10-r,. ,g3S- zip:_Ot7L/71 v City: State: {)f- Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: tJ1;rLuL- Address: Phone #: City: State: Zip: Construction Contractors Registration #: 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 . ~&~ Signature ~ /.Jo/f3 Uate FOR OFFICE USE Issued By: Job #: 0;)1 cSDL/ ~.~. I Date of Application: Receipt #: C);rq tj ! ()/ oD' CJ3 Total Amount Collected: It' I~. 7(;