HomeMy WebLinkAboutPermit Backflow Test 1990-3-27
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
Job Location: Q.a ~() \. ro(\~ [\ S-mOO r/
Assessors Map #: \ f) D~ ?If,4-8.. . Tax Lot #: [)Q9rx::J.
Owner: S\lj\J.. ~'a 0 J:9 {\ \1u J\ 1't\ ()t 0.hYll& ,
Address: ~Aq(~\j m (j lJ7) PhOnW:.-1flJ.o-qj!j'l}
City: ~':l..t=U[t/ State: (91?) Zip: qf)1-t1 I) ,
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Backflow Permit is $15,00 + $0,75 State Surcharge
Contractor: r U.AJ ~
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Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
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 all information on this application/permit is
correct,
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Date
FOR OFFICE USE
Date of Application: ~. {j'lE/ );J06 #: qf)n \~.l}
Receipt #:-11 ()~ Issued By:. t::1')1.fY"} )
Total Amount Collected: 1~.1).."""", '