HomeMy WebLinkAboutPermit Backflow Test 1993-1-28
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Office: 726-3759.
INSPECTION LINE: 726-37~~.. .
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Assessors t~ap II: / ?...:!P2-;?:s'- 9'<-- Tax Lot II: ~-5<'e:>/,
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Address: ~. Phone #:-2"2.11!:"-eSJ..i!I2B
City: -1'~p_ State: 4/11: Zip: ~?'Y~
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225 Fifth Street
Springfield, Oregon 97477
Job Location:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: /. Ji;//.w .;f~~- ?~~....s~~-,/~ .
Address: "2::>~/.?W~A1nI."'41'~ Phone #:_h%';;;>-/'Y/+'
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rV&r~iIE"/ State: ~ _ Zip: ~~
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Construction Contractors Registration #: J'~~~~
City:
Expires: :?~~
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By signing this permitlapplication, 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 .
s.t1(fd - I /
19na ure V
/-2f-93
Date
FOR OFFICE USE
Date of Application: /,..,79-?"3
Receipt 1/: ?'?.6'K Issued By:
Total Amount Collected: ~~ ~~
Job #: "'7""3~/eP5
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