HomeMy WebLinkAboutPermit Backflow Test 1990-7-31
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street Office: 726-3759,
Springfield, Oregon 97477 INSPECTION LINE: 726-3769
Job Location: ??LfLf fJrpC;,11-ff / /!.i/lP
Assessors Map II: 17r)~3c.j()() Tax Lot II: ISd!J6
Owner: lY/rG, ~e:-\l.)\E>t..1 l. ::;\~(J,\ .A."'I:\
Addres s: f\ 4--,\- ~ '12> t=-~c., 0 It
City: ~\=l~\tJ6~\f:!:-L1)
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Phone II:
'+ 410 - 0 161o~
Zip: 9!:/4,+1-
State: ORi?6-/)D<1
Backflow Permit is $15.00 + $0.75 State Surcharge
contractor:.J!n p~ I IlMJ-ScMJ(1j I '!he.
Address: Q3L/,31 t1VeY Ed, Phone II: qtJ f. /&/3
City: ~..u1r~ State: ()R.... ziP:j1 W
w~~~cXiJ\ct: f, 5&'ir~ "pi"" <:],3/-10
By signing this permitlapplication, 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 applicationlpermit is
correct.
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Signature
:t0~ /99n
Date 0 I
FOR OFFICE USE
. Date of Application: 7<1 J -9()
Receipt II: J 7'6'XS Issued By:
Total Amount Collected: f~,~t;
Job II: C; DZJClkC;
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