HomeMy WebLinkAboutPermit Backflow Test 2001-7-19
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SPRINGFIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: '7u~ &?# &J,fe//A'~
.. ASSESSORS MAP #: /7/J.J 2- i 4-'5
OVNER: .I--~_J "~.... ./ 4--,<-..$
TAX LOT #: tfJ7..J(?"2-
ADDRESS:
CITY:
STATE:
PHONE #: 7# - ~(J~
ZIP:
BACKFLOII PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
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CONTRACTOR: i/u._77?-X -:vf'rf/QA'7;t.:,./ ./#,-,,dsc~---
ADDRESS: :2.S-;L:2 C' ~...,~rl'A'.J 2-./ PHONE #:9.'5'J-:5::u. $-
CITY: lAM'<-"'.? STATE:Od: ZIP: '3'71'3-'>
CONSTRUCTION CONTRACTORS REGISTRATION #: / /'3' ~ 2.
EXPIRES: . <!:/-o.2
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS
CORRECT.
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DATE
FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
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ISSUED BY:
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DATE OF APPLICATION:
RECEIPT #:
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