HomeMy WebLinkAboutPermit Backflow Test 1990-1-24
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 313/5 m~
Assessors Map' II: 1 ( ..- D'd- ..... ,-3 J -
Owner: ~fAA1~ ~
Address: /5 D) rJ I ) % t!:L
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L1- .. Tax Lot II:
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Phone II:
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Zip: Q7'-177
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City:
State:
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: \IDS P\()..;YY\f)-1 V\j
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City: f::u ~ State: DR- Zip: 0; 7Lj() ~
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Construction Contractors Registration II: ;}D-IF3Pf) Expires: t-/~-3D-'1()
Address:
Phone II:
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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
Total Amount Collected:
I ssued By:
JS,,75
Job II: qaol;O;
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Date of Application: J-dL/ - q [)
Receipt II: J5Y'.C;~