HomeMy WebLinkAboutPermit Backflow Test 1994-1-19
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S.INGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Job Location: /~~6 MA-/A/ ~
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Assessors Map #: I ? -~"7 - 3..,; ~~;2...
Owner: ~AtC ~~/~~
Address: ? rt6? ;7f3~- ?y...;-s-
City: C~""'a: State:
Offi ce: 726-3759
INSf'ECTIOH LINE, '26-3769 *..
Tax Lot #: c:> "AffG.O )
225 Fifth Street
Springfield, Oregon 97477
Phone II:
~. Zip:
Backflow Permit is $15.00 + $0.75 State Surcharge .)(~
Contractor: PeF~:r !~~ 74t:::.-~~:.---=-
Address: ?3~~~~q.~~~.Phone II: ~-~~
City: ~~D State:~. Zip: q./97~
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Construction Contractors Registration II: ~~ .7>.8 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 applicationlpermit is
correct .
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Signape y6f
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1-/;- 9/
Uate
FOR OFFICE USE
Date of Application: /~/~"9 Y
Receipt #: //,/p~
I ssued By:
Job #: qH'~~
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Total Amount Collected: -::ZL>_ C>t?