HomeMy WebLinkAboutPermit Backflow Test 1990-8-3
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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: V2::01'\ ~~\()\0)Qf )?\(li M f --1
Assessors~.ap 0: \ ~0?J~C"l.~3, -, Tax Lot 0: ()~\W '
Owner: ~')\\(\ \\ \ I~ ~nf'),() 0 ~') .
Addresrr- \~ ~.O ~~ t\)U-.") \' 6Y(\O~~~e-o:.J041 --I.o'?>~ \(
City: \\)()YT\Cln0t State: L)IL- ZiP:.-91?7~
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Backflow Permit is $15.00 + $0.75 State Surcharge" AA'~ I
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Address: \) () ~y. 03?JOi, . Phone 0: 0 .
City:. \lOctf\{1_ State: ~ Zip:
Construction c~tractors Registration 0: n (~ \ (j Expires: '?)t:JJL a(
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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 applicationlpermit is
correct.
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Signature \ ", I
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FOR OFFICE USE
Date of Application: p:>. ~ .q(~~ Job 0: ~ qn()8')~
Receipt 0: \1 C\4~ Issued By: I:J) L[)Q ./
Total Amount collect~d; \ ~. ~~ - .