HomeMy WebLinkAboutPermit Backflow Test 1995-9-15
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SPRINIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
'OrVIcnl 726~~159
INSPECTION LINE: 726-3769
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. JOB LOCATION: ,1fc I ~) ((..f I ~ Cf/Z... t[7tJ7!
ASSESSORS MAP 11: /?y;;)~'~Y'~? . TAX LOT 11: &6'..e'~c;?
OIINER: ,ISvY8'&' ~/~!(~ -~h,AW' ~~/;>!?-
ADDRESS: 2~e./.7 0 b-/h,{'L~ f':::__r7 PHONE 11: 6$;;>..q,.e:-s;-
CITY:' ~V.::::.a:/"'}./C STATE: ~. ZIP: q~.;--
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARCk) + $.45 (AHH1N.
CONTRACTOR: ~1UU(';' ~I"'-~ ~..
ADDRESS: f1 (J. 4-x ~ PHONE 11:
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CITY: ~ STATE: ()K.. '
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.-CONSTRUCTION CONTRACTORS REGISTRATION 11: /j 25tJ
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r~~; i; S16.20
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ZIP: q 1f-zt
EXPIRES: 1- w- r:;
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV 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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SIGNATuRE d
DATE
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. FOR OFFICE USE
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DATE OF APPLICATION: e::7~/~-;-
RECEIPT 11: /~~S'V ISSUED BY:
TOTAL AMOUNT COLLECTED: /~ :c>~
. JOB 11:.. 9~6;;>5/
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