HomeMy WebLinkAboutPermit Backflow Test 1993-7-20
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Job Location: &I6~ ra}vw ~ PL
Assessors Map #:
Owner: 9?\tr (I.~ 0..(1 ()Y)
A~dresS: q0~ 1=rJ.";Y V\J 0 J
Clty: Soi'J
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Office: 726-3759.
INSPECTION LINE: 726-3769
(OaHv-{e SubdiYSI~YJ &fz~)
225 Fifth Street
Springfield, Oregon 97477
Tax Lot #:
PL
Phone #: 7L/j - 77'i 3
()f2- Zip: q7'l17
State:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: tw'r\U;V
Address: Phone U:
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 ate that all information on this application/permit is
correct.
Signatur -
7-zo- ~3
Date
FOR OFFICE USE
Date of Application: 1-w -c; ~
C( 0?L
Receipt 1/:
I ssued By:
Job 1/:
tVVvv-o
Cf2-/ to 96
Total Amount Collected:
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