HomeMy WebLinkAboutPermit Backflow Test 1990-9-10
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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
Job Location: (oq(J C?)Htu)CIv
Assessors M<lp U: r,O "-'3Y VV
Owner: r.:lJ. -h. .-e ~ ~\""JVV\ -e 'S
Address: :299 ~ fl1..f...-+j) I j c..,C c:.,
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Clty. ._ur_Q.L.)..Q_ State:
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Tax Lot D: ()(( I \0
Phone D: L(gc; 3/7~
()/2- Zip: V7L!O!
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: f..u..;::,-fmn rv I.LGWi.ttililCv
Address: 32L( X ILO,J.. V\f2ru8.1
City:, bu c.L v\..9- State: ?\t2_
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Construction Contractors Registration D: L{(q ~I
Phone U: 3,Lf 7_1/ L{ S
Zip: 17L/tlf
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Expires: L/ - 27 - C; 2-
By signing this permit/<lpplication, I agree to call for <In inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state th<lt <Ill information on this application/permit is
correct.
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Signature ~
/-/-t:7- J',?)
Uate
FOR OFFICE USE
Date of Application: t:f' -ID Jf(,)
Receipt II: I ~2 L( (j Issued By:
Total Amount Collected: 1~.71")
Job D: q ()l) L(~7
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