HomeMy WebLinkAboutPermit Backflow Test 1998-3-9
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD ~
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-37. 9 . --~
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 .',l
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ASSESSORS MAP #: n 0 ~:J-J, LtC-{
.oWNER:J:;~~ /( I--~~s.
JOB LOCATION:
TAX LOT #:
0(;;700
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ADDRESS:
PHONE #: ~if 3/?6'
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CITY:
STATE:
ZIP:
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ~\), l{c, ,L.,je".M ) 2f.f~ _ k~1 Tnc,.
ADDRESS: 4'06750 /'h,,;f;;;,Z,k'\ ,~/ PHONE #: 7<Y?/- /?'3~
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CITY: --,?,,,r1,, STATE: f)$:?_ ZIP,: c?7-7'75
CONSTRUCTION CONTRACTORS REGISTRATION #: C::>.<"~ Z3' (:) EXPIRES: f~:
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 PERMIT/APPLICATION IS
CORRECT. ' .'
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SIGNATURJ:; , ,
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DATE
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FOR OFFICE USE
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DATE OF APPLICATION:,J I CII &, '6 JOB <<: C( {II J- rr
RECEIPT #:. ()J--&;()4! ISSUED BY: n . fY\ Oc.k~.d'o
TOTAL AMOUNT COLLECTED:. -tb 1 ~ . OD
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