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HomeMy WebLinkAboutPermit Backflow Test 1993-7-20 . . BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 22~ Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: 2/7/5 FIA'm Assessors Map #: /7(13 2.c; 12- Tax Lot #: /An/J7) Owner: 5Tu fidA?6P Address: 2/7~ F//p 77-1 Phone #: ?~7-?S~O City: y~ State: /J}(f' Zip: '7>7-177 Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: to /,(/;<i/M LAv,)r~~ / /~~ ~.A>1 J Address: /7//J b'#-/./:,c/')R. - . City: WC:;-;"':;',,-TJ= State: Construction Contractors Registration H: Phone #: t;.~q -~724 ~ Zip: <374crl J/Jf'/'? Expires: S"~0-:L , . 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 . 1(j~ 'f- Sfgnature 7- ;2tJ--77 uate FOR OFFICE USE Date of Application: ;;/2~'J.7 Receipt II: "35"8'5 Issued By: Total Amount Collected: ~5,7 5 Job #: 9,'S/CJ~9 #~. I.;J hI!-