Loading...
HomeMy WebLinkAboutPermit Backflow Test 1993-11-19 . .~ SPRINGFIELD 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 Locat i on: 'I CA it-\- \.J\ ~ i':u_)QUJ \ ~\n.[' 9- Assessors Map II: ,_ ' ~x-Lot II: Owner: f~ \ \ >lJ\\ c\ \J\ D.-\ Address: & ~ (\). t\t \. C'(~ \. ~ 0 - I City: ~\ )~L te: Backflow Permit is $15.00~5 State Surcharge Contractor:\. \\1\.t'J\\GU r ~OAS-'\3\l !\"""1dj,. '\ I ) Zip: '-'\ nl lL-, Address: Phone II: City: State: Zip: Expires: Construction Contractors Registration II: 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. l o\\\~ ~~(\~tQ ~ ' l~~t. ~ ~ (llj~ "<t, ~ fOR OffICE USE GDL L{~ \t'rlQ - - " Date of Application: \'\. \lJ(.CJ\~ Receipt II: \ \)l\b~ Issued By: Total Amount Collected: \~.1S >JI~~'":-) 0\ --