HomeMy WebLinkAboutPermit Backflow Test 1990-9-19
.
.
SPRINGFIELD
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELO
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location:
'-~()c:\ '- ~it ~ G.Juv
Assessofs flap 0: '1\.' Tax Lot 0:
Owner:Nrf'nrt J.XtU LA-11.1 t-fl1/S
Address: , I qq.J1 - U..YYYf Phone 0:
City: <Q)9S~ StatQ: <- _J(lAL('\()l\Zi~: L{l~
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: l J01 LJf\OP .-/
Address:
Phone n:
City: .
State:
Zip:
Expires:
Construction Contractors Registration H:
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.
Aul<J.. )J~'.-
Signature
. '--"'-
Q!/<l/90
~
FOR OFFICE USE
Date of Application: q- /C/ -9() ~ob,n: {({{)7J3
Receipt II: I fs~/4 Issued By: \,Z)I/Y1 ')
Total Amount Col'lected: l~. '1___c::::.... '-' - ~ .