HomeMy WebLinkAboutSpecial Inspection Fire Department Referral 4-7-12
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION.
'" . CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street .
Spr i ngfi.e 1 d, ,Oregon 97477
Office: 726-3759.
INS~ECTION lINE: .726~3769
Job Location:
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Assessors Map #:
Owner: ;/AlkP,HgA/ ;(1,5-e-!9-
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Tax Lot #:
Address: '2 ~IO V CJ I/o
City: -S~;f}~rq ~ ;~)"LJ
Phone fI:
State: tt),f/E
Zip:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:. f/I.LN~~~~,;34-r/~ "',,-
Address: K& ~~ ~.r-'/
Phone II: 9 S J'- '3' ~ IJ-
City: z/...e..,...c-<::7J.1-
State:
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Zip: ~?ytr7
Expires: d- r-J ~ -<7'(
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Construction Contractors Registration #:
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/permtt is
correct.
U//L
SiWh~ure
7-1'::< -' ;7 y
Uate
FOR OFFICE USE
Total Amount Collected:
7//2-/7d
I I
Issued By:
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Job. #:" 9+103 '7
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Date of Application:
Receipt II: /3~~ r