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HomeMy WebLinkAboutPermit Backflow Test 1991-10-17 . 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: ...-::? ~ t70 t"'?~o//'hP/c 5r. Assessors Hap If: 17~n2-"30-e:>~, Tax Lot H: O/"'T-:<B Owner: E~~#C2/ #Y2;)P.A'VL.../e::.S Address: 3,-/2.2 C/c.. ~,..,..P/C Phone H: 7't"7~:z/~ City: 0/?r-U? State: C:::S;:;>. Zip: 07"-1:?fit I' Backflow Permit is $15.00 + $0.75 State Surcharge ~~~ Contractor: ,4') fpf'/E/? Address: Phone H: City: State: Zip: Construction Contractors Registration H: 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 also state that all information on this application/permit is correct. SiO,tff ~~ ~/f/ FOR OFFICE USE Receipt II: "2/6:zc:::l Total Amount Collected: Issued By: Job H: q/09~ 3 .~~~~ Date of Application: /L>-/7-9/ --:? / _ -5?::>