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\ --