HomeMy WebLinkAboutPermit Backflow Test 1990-3-16
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SPAIFIELD
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: l~ac;- Cf'''a~v
Assessors Map #: \'\D~Aln.E\3
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6",,';'1 . \-.-C.... r r"", '-V \. ~ ~ ~ ^
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P"Cl "uK'"" Pc..(!:w, E.. Phone #:
City:_ S~l ~i ~rcl cl State: Or~"'t bo"
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Tax Lot #:
EA.'5"~
OJ,ncD
Address:
175 0.,,-
Zip: '1l Lf 7{
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
n G5 is <4..-, Y''i c, CI. +\ 0 ~
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Address: \ Y. ~O Gr~ A-c.~ V cl Phone #:
City: ~ eld- State: C)~1'1"'-
Construction Contractors Registration #: 1\ 5 '2.. ~
SY1- ~2.8'7
Zip: Cfll../Dt
Expires: S-~'-~c)
By signing this permitlapplication, 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 applicationlpermit is
correct.
Si'''t"'~- ~
Mc..('ck
Date
(Co) 1<1.'1 cJ
FOR OFFICE USE
Date of Application: MIhlUl It,117'D
Receipt #: / l o?f'f7 Iss~ed By:
Total Amount Collected; ~ 7) 75
Job II: 9:;;qr') 959
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