HomeMy WebLinkAboutPermit Backflow Test 1989-12-28
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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
wocation: . ~~ ~ ~()\\C) t,(l )
Asses:;(~~pV~\'~ \ '1 o'~ 7\49 ~ Tax Lot 11: 03\ CU
Owner: ~). -\-\ ^ \\. G . \6 \-\()ffi 0 r::.J ) .
Address: ~CJ(\ \ '\\\C\~\-()\ \n~ Phone 11: 4-~~ 0\'\l ()
City: . f~Q n Q , State: (~J Zi~: C\'"'\4() \
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~ ~ \!\A ~S'\\.~\f\nJ
Address: ' Ph~S~:
City: Y). ;('~9--,n 0 . State: (UU
Construction co/;;tractors Registration 11: 4\ C\ ~ \
Zip:
EXPires:.11 fJ.0 l!1o
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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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ts-ignature r
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Date
FOR OFFICE USE
Date of Application:. I ~ -iJ K #?\ ~ .-l Joll 11: 8 q n( &
Receipt 11: I cJn5 X' Issued By: (J)/ffi )
Total Amount Collected: - I ~ .0 S