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HomeMy WebLinkAboutPermit Backflow Test 1993-7-19 .,.. I BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 '. Job Location: 0/~ :}-r......r:AAJC<...d Assessors r~ap H: (')",.1( l-^ '" 10+ ~"I O-eOrPL Tax Lot H: City: ~, A (', 6 ~~.A<. o C1, c::... :1-", ,;'A.< Jl'A.<d btrv . vv/t.. I j"f_ Pi""" Phone H: State: 01{ jyl -<6o~'--1 Zip: qj'-Oi Owner: Address: Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: 7'vv\u\o.fJrf ~o./Y'>./,j<::"O,...{H, Address: ~Lf Q>? I 'YY\cctk.,..J<:" -Q--O. Phone H: ILl) -~04-h City: C; .1-"',,1__0 State: ()Q. o Construction Contractors Registration H: ~~ I~ Zip: 0/40<: Expires: 'Ie;:>., 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. j,9~ .' ..signature () ~.dAA/V1.- - {/ (7 J -It:! ~.", Date FOR OFFICE USE Date of Application: -; /,~ 1<;-:>, Receipt II: qSs R Issued Job H: 0~ /{)~:s Total Amount Collected: By: 11 \ S. I C, \$0B