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HomeMy WebLinkAboutPermit Backflow Test 1994-7-20 / . ., BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Office: 726-3759. Springfield, Oregon 97477 INSPECTION LINE: 726-3769 ~ QCLyA~ ' Job Location: CL.Ove.WACE- ,A;.YT<,.. -:"'h~\L~AI..~ -~ . 9L\~';:I~ Assessors 1~i1p II: f\()~Qf:) 04 Tax Lot 0: nQ,locr) Owner: , . ~ YUA-N '(2.. (a e'V . c/o Mm.", \)A-( ~~, U......17~.,;:N""1A..(p~i1 Phone 0:_\ -5'Y'~-7-~\(-'2,Ul. Zip: ") 'TZ.j? "'L Address: VD ~ 'R"2-\!?(o City: fu (t\L.IA-N D ,State: oiL Bi1ckf10w Permit is $15.00 + $0.75 State Surcharge - Contractor: \ \-\-<::wV\,O<.("\~ l A- N >) "cA-\?~. ( U. City: fa t~DX \\ S'c..o'L eV(;.-{.NtL State: 0\7 Dhone 0: CD~Cs:,-3,4-v;9 zip:'17lt<tO Address: Construction Contractors Registration 0: 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 a state that all information on this application/permit is correct . 7/~/'1'i Uate I Sign7el >/ / FOR OFFICE USE Date of Application: '7,~n.q4- ,Job 0: Receipt 0: \?-Act1/ Issued By:CJ\IDl:A Total Amount Collected: \~ .~~ ' c(5l~ J