HomeMy WebLinkAboutPermit Backflow Test 1994-6-3
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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:
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Tax Lot If:
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Phone 11:\44 .\\r!o\ _ _'
Zip: qtrT'fi
Backflow Pennit
Contractor:
Address:
Phone II:
City:
State:
Zip:
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Construction Contractors Registration R:
Expires:
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.
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FOR OFFICE USE
Total Amount Collected:
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Date of Application:
Receipt If: \~\~f)