HomeMy WebLinkAboutPermit Backflow Test 1994-8-3
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILOING.SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: / 'tiff' [)EL.ec?0,E A \.IF
Assessors Map H: t lO'2,1_<A~3
Owner:, QEfi,p Frl2J2.E/IJ
Address: jLj9'S' 0t3U?~,5~ At/1=- Phone U: 7'77 - h 713'
City: _-<PEl) State: dP' Zip: CJ7Z/77
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Tax Lot 1I:.6..5J 0 0
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: D.=?TA /.Jl.No:JC:~Jle
Address: 525 rk/2/t1 .t-N
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Phone 0: ~'i?r-9/Y7"
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City: 1=1./) cfl r State: &Z..-
Constru'Eti on Contractors Regi strati on II: lit, L/ 0
Zip: q72;1o~
Expires: / J- 3cJ -9'~
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.
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FOR OFFICE USE
Date of Application: ~~~~~
Receipt II: /4/5i? )' Issued By:
Total Amount Co~lected: /0 ?- [)
Job II: C},,/ / / iO--,n
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