HomeMy WebLinkAboutPermit Backflow Test 1994-4-14
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
Job Location: .~~tc, I \lY)c:;~~)
Assessors Map H: \ I ():l ~ I 4 J-.
Owner: W...f dJ ::itA~ v fJ..s'SfJ "'- ..
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Address: \) n. ~ ,',,/ 4S /---,
City: ~V 1,.,1 State:
Office: 726-3759.
INSPECTION LINE, 726-3769,~
Tax Lot II: '00 '-Ij() I ~
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225 Fifth Street
Springfield, Oregon 97477
Phone II: I 4/- l-{~fJ I
()(.Z Zip: CfJ471
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~ 'I r:vfr..4 ,- W~
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Address: 9n. f\,,~ ,n<.::::;)h
City: erA A '-VM 0 State: oA.
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Construction Contractors Registration II:
Phone II: I Lf / - ~d4-:J
Zip: Cf) lJ:O I
Expires:
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 an information on this application/permit is
correct.
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Uate
FOR OFFICE USE
Date of Application: Lf -IU -C1L:(
Receipt II: I'~d-q?, Issued By:
Job II:
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Total Amount Collected:
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