HomeMy WebLinkAboutPermit Backflow Test 1993-6-30
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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 #:
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Address: C1;;r1 :r!l1(~4:M fl.
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Assessors r~ap
Owner: ~.t\e-...
Phone #:
10-r,. ,g3S-
zip:_Ot7L/71
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City:
State:
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
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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 .
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Signature
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FOR OFFICE USE
Issued By:
Job #: 0;)1 cSDL/
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Date of Application:
Receipt #: C);rq tj
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Total Amount Collected: It' I~. 7(;