HomeMy WebLinkAboutPermit Backflow Test 1993-6-4
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION '
225 Fifth Street
Springfield, Oregon 97477
, Office:
INSPECTION LINE:
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726--
726-3769
Job Location: ,-~V-).\, ~ ~s-it '0 Q.N_) .
Assesso;s r1tp^ H: \f')~?i!\ .. \ Tax Lot H: CtSSf'{)
Owner: m ~ Y1n ~ Dr>\ {L.\",,\ )
Citp. ~ . n \ ~ 0 ~ rD. S .t" f()\ u ~ lip, ClWlfJ
Backflow Permit is $1~0 + $0.75 State Surcharge
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City:~ " State: (\JJt~flf\ Zip: ~~
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By signing this perm~tion. 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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FOR OFFICE USE
Date of Application: (J1 ~ .C1;-:s
Receipt II: ~ /) Issued By:
Total Amount Collected~ \:\ .rl~
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