HomeMy WebLinkAboutPermit Backflow Test 2001-11-16 (2)
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CITY OF SPRINGFIELD
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BACKFLOW PRE\< LL' HON DEVICE PERMIT APPUCATION
CI1Y OF SPRINGFIELD
COMMUNITY SERVICES DMSION - BUILDING SAFETY
225 Fifth Street
Sprhlgfield, Oreglll1 97477
Office: 726-3759
INrCTION LlNE: 726.3769
~rnell D II 171.p)~a..h+ Sl-r-e-e
\;mr:LotII: . I SPti"1rti~(d r.v
lob Locmicn: AI "orel, I t:\.,Lj I or ~'-T () 00
Assessors Map #:
0wD.cr: A \ { () 12- \) ~ 1-0 If
Address: L\ DC; . N . '\A l( 'S-j-y~~t-
City: C:J pY;111i 1:1 d . State: tsr
BACKFLOWPERMIT IS $51.75 (includes Pemrit Fee, State Surduugc & ~ve Feel .
Phone#:
'13&2 - 3 L/ LJ L/
ZipPY7 L-t I '7
Contractar: nWiL d -+ 0vv;nn:W] ~ C1p-ViV11G 1-eVl--
Addtts~: \ '2 (0 )' N. ~ Sfv\ 01l/'e -tl_t Ph~#: 141-lll~-
City: C?JpY" routl crt 0\ _Stllt2: erv Zip:~ g
ConstlUction Can1Iactors Registration#: to '2"1 ~o . ,...'!'~.~: I rJ 0 I
By signing this pmmiiJapplieatiClll, I ~to call for lUlinspectiol1oneethe'ba.cldl~ r"'-.:rm dcvicehas
been installed and is visl"bl.e for inspectian (726-3769). I also state that all infommtion on this pcrmitlapplieatiClll
is conect.
G, ~ ~~cd o--nJd.
Signature
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Date I
FOR OFFICE USE
Date of Applieaticn: . I ( )6;:;
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Checked for Dc:Iinquau:ies:
VALIDATION: .
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Cbt:ckcd for Historical Status: .
-r90:i:l3IHS~
:39Nl:!H8..,
gL'-rg $ :Z:083i:1 lHl:!
100<': n~DN:31l:!O
89<':LOOO~JO:#SNl:!i:ll
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