HomeMy WebLinkAboutPermit Backflow Test 1995-9-12
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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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JOB LOCATION: /2 Y/ I.?~~T ~';;;--.A3~
. ASSESSORS MAP #: /7""",~' <' ?-":;> ':1 TAX LOT #:
OIlNER: 6~";"6(!!:' ~~~~~
ADDRESS: /'2 t;'./ 1# ~(",~/:?7~"""'C::::: PHON!;: #:
CITY: .:5~?.z::> _ STATE: ,L~~.
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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ZIP: q?f/?,?
CONTRACTOR:
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ADDRESS:
PHONE #:
CITY:
STATE:
ZIP:
.~ONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. .
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SIGNAflfRIIV~-
f'~~S
DA'rE
FOR OFFICE USE
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DATE OF APPLICATION: q-/?, 9~
RECEIPT it: /~~ ISSUED BY:
TOTAL AMOUNT COLLECTED: ~~. :?~
JOB #: "75'/$/75:"""'
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