HomeMy WebLinkAboutPermit Backflow Test 1994-7-20
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street Office: 726-3759.
Springfield, Oregon 97477 INSPECTION LINE: 726-3769
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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:
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Zip: ") 'TZ.j? "'L
Address:
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City:
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Bi1ckf10w Permit is $15.00 + $0.75 State Surcharge
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Contractor: \ \-\-<::wV\,O<.("\~ l A- N >) "cA-\?~. ( U.
City:
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eV(;.-{.NtL State: 0\7
Dhone 0: CD~Cs:,-3,4-v;9
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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 .
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FOR OFFICE USE
Date of Application: '7,~n.q4- ,Job 0:
Receipt 0: \?-Act1/ Issued By:CJ\IDl:A
Total Amount Collected: \~ .~~ '
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