HomeMy WebLinkAboutPermit Backflow Test 1993-7-1
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILOING SAFETY OIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: I ()BC\~ ~(2\S\~l rl:-> :-
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Owner\ M\.1n 1 r A ~ " ~ ~'\\C\...<:;fJ1'\./
Address: l ()~'?J rb~mLt)) Phone D: r 14-0 ~'l\rJ(f
City: ~)) X f\(l~. 0 ~ (\) ~tate: (V h 0 .f\~- Zip: arv\ A
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Backflow Permit is $15.00 + $0.75 S:ate Surcharge
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Address: \.'1 \ T\ ~r Yo, \~J\ it /J 1 Phone D: lnm-:~
City:}} lOQn Q ./ State:JD.AQ~ Zip: qf[4()f
Construction C~ntractors Registration D:~ ISf) Expires: \.. t=)~ ~ l.q4
By signing this permit/application, I agree to call for an inspection once the
backf10w prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct.
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Signature /
7-/-7'3'
Date
FOR OFFICE USE
Date of Applic~r~: , 'X ;. q.3 0 Job-D:
Receipt II: '-l..:.LJ-)n Issued OY:~JJ'() )
Total Amount Collecte~: !,,~. '7,~ . .
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