HomeMy WebLinkAboutPermit Backflow Test 1991-8-8
.
.
SPRINGFIELD
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:
q<6~ r~ ~.
Assessors Map II: /7/13 ,<:.(1 b /
j~ L. \'<:CL.L€::Y
Address: q~~ R~II\le,.,\v f)R. .
City:~
~\ ~\)
Tax Lot 0: t1I"JCftfCJ
Owner:
State:
Phone 0: ~ l{b- (.,'2J.I )..-
QR- Zip: cnlcn
Backflow Permit is $15.00 + $0.75 State Surcharge
Address:
b~
~
Phone n:
Contractor:
City:
State:
Zip:
Construction Contractors Registration 0:
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.
~,~
<b--<6r-91
Uate
FOR OFFICE USE
Oate of Application:
Receipt fl:..:?C/ 95/
Total Amount Collected:
,?;;/~h/
/ /.
Issued By:
j So 7 J-
Job n: q jnQ.4.- '1-
//#~