HomeMy WebLinkAboutPermit Backflow Test 1997-5-16
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225. FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ,7~/71) In/7./A?. .JIcnr
.. ASSESSORS MAP #: /7&7 L'? 3 _? 2-
OYNER: O/W,.-r.-J12- R_~~J<
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ADDRESS:.. '32>11.> l-/~.."k
CITY:~j-,'nil
TAX LOT #: ~ Z~~
STATE:
PHONE #:
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ZIP: CJ7<1?7
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE~ = $16.20
CONTRACTOR: -b; .~ ,.th;;~.--1L
ADDRESS:
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PHONE #:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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DATE
FOR OFFICE USE
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DATE OF APPLICATION:
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ISSUED BY:
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RECEIPT #:
TOTAL AMOUNT COLLECTED:
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