HomeMy WebLinkAboutPermit Backflow Test 2001-12-31
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
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Tax Lot#: 0 Z I 0 z...
Address: ~O ~ 0;< ~;)(( Z ') Phone#: 7 L(<{ - 2 bb 0
City: L-u.. f:--to7'f t"- State: c::scL. Zip: '77 L{ 0 I
BACKFLOW PERMIT 19c1Udes Permit Fee, State Surcharge & Administrative Fee)
Contractor: J-Iu^' / -c./('" J/f',1"/.....". /ff_".j: ~/?~-t::Jsc:,,~----...
Address: 1. S-;>.';< b .sri-..-f'A-.vd--A'A'~ /4
Phone#: 9J.r-- 3'..:1/, r~
City: 1/~uP--<.__ --r:::>I--
State: &A
Zip: 9-?~.!!r'/
Construction Contractors Registration#: / /3'? 2-
, Expires:
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By signing this pennitlapplication, 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 permit/application
is correct,
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Date
FOR OFFICE USE
Date of Application: / 2-/S f I
, Checked for Delinquencies:
Job#: 0/ - 00 Sbb -0 I
Checked for Historical Status:
VALIDATION: '
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