HomeMy WebLinkAboutPermit Backflow Test 1994-1-24
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225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:.
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726-3759,c
726-3769
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Job Location:
":2 4"a )$o?..?Z/'h ?7..
Assessors Map #: /7-r:J2. ~3""- '"3' /
Owner:"P A1./I~ /f z=:7f C i!? 7"
Address:~ c:.__~. ~ .N"'~.
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City: ~AlLF,/iI';? State:
Tax Lot II: tt:> ~/~2.
,JJI;v"9 Phone #: CS"~ )~S-.C;ci>-<..-)
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: .1?/4Ae7~~+" h~~~
Address: "P-L? ~.b'Y 7~S'2.~ Phone II:
City: Cor::;..~e:- State: ~_
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Zip:?? >C;;,p/
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Construction Contractors Registration II: '2c:'.y95'P..2:?Expires: /'2~~/""'3Jo/'
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 application/permit is
correct.
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Signature:.~ ~~.
FOR OFFICE USE
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Receipt II: 1/ y?Y
Total .Amount Collected:
Issued By:
Job II:. ql/"tP~?
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Date of Application: I'--~I'-~~~
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