HomeMy WebLinkAboutPermit Backflow Test 2001-6-29
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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
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ASSESSORS MAP j!: 170 323cf3 TAX LOT j!: O?I'~O
OI/NER: . ~e- f2/D~ As'
ADDRESS:
CITY:
PHONE j!:
STATE:
ZIP:
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50
CONTRACTOR: ~~.s.LJ ~a-41C,l ftf"'~~ ;J;:c. '
ADDRESS: PD. g >< 7C;;:vr
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PHONE j!:
CITY: ?C4~
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CONSTRUCTION CONTRACTORS REGISTRATION j!:
STATE: 6,J(.
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ZIP: c'1'7<Yo I'
EXPIRES: 0/-02-0,2
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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SIGNATURE ~- ~ , ..~-
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DAtt I I
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FOR OFFICE USE
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DATE OF APPLICATION: D 62-76 (
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TOTAL AMOUNT COLLECTED:
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ISSUED BY:
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RECEIPT j!:
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