HomeMy WebLinkAboutPermit Backflow Test 1989-12-28
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SPR,tI,'ELD
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:
12D'l ((j b\CLf\ f\ll j
Assessgrs~Map II:
Owner: ~d:\ \ \ \) '~~l1\N) ~
Address: 2r)~\ '\\\()i()\\t)~ Phonell:4~S-~\'1lo
City: Y 1 ~Q f\SL --' State: (\)i\ 0 ()f)\\ Zip: Q'l4() I
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: 0 i \. c\"\:f\"'\\\ '\\1 \.. f'f\. t\\ ~
Address: Phone II:
City: y" \011 f\Q _ State: rCJ.e___
Construction contr~tors Registration II: ~\~~ \
Tax Lot II:
Zip:
Expires: 4- 211.90
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.
~7/;P ~~
Signature ' .
/.;?-~Y-r~
Date
FOR OFFICE USE
Date of APPlication)/)' 6J R. ~q
Receipt II: \ ~ 0\ Or) Issued By:
Total Amount Collecte~: - \~.f)~
tKJOb II: Rqnlo~ 0
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