HomeMy WebLinkAboutPermit Backflow Test 1990-8-30
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location:
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MAl... .,r.........
Assessors Map II: '1 oz. ~1. ... Z.
Tax Lot U: l.oo
Owner: Jo\h'\ ~..U>.~\)
Address: 4D 11.<::' 1<.~...u .....1I~ ..",.
Phone U: 7'1'-:',"12."1
City: ~ ""'N" !:',ILL"
State: O~Ec.."'N
Zip: "7'-178
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
.Jo\.lt-\ \..l"'f\..A..MO ('_O"<IJ:.'r. _ \HL.
Address: \ .....1 \..,4.......... ~r. .
PhoneU: "51-1<;".8100
City:, ~~ll.\"'<'~Il1.Lt)
State:
O'R.~c..O""
Zip: Ql'11'
Construction Contractors Registration H: '1(.01 I
Expires: 7 hi':> Iq I
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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FOR OFFICE USE
Receipt II: {RJ ]{)
I ssued By:
Job U:
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Date of Application: FS-3:)-QO
Total Amount Collected: /6.7?i