HomeMy WebLinkAboutPermit Backflow Test 1993-8-4
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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: 5ib '7 DJe::elYrimv I
Assessors t~ap H: /7/J"t. 1...pC /:3 Tax Lot H: (1!.C)1'J
Owner: N(//c6 U/A-( S:;b.J
Address: 5~9 ~b ./?-:7/JA.!/ Phone H:
City: 1J,/t?~, State: ~. Zip: 977"'77
Backflow Permit is $15.00 + $0.75 State Surcharge
Address:
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Phone ":
Contractor:
City:
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State:
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Expires: 001'
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/permit is
correct.
(:'ignature
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Date
FOR OFFICE USE
Date of Application: S8 /4 /9 ~
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Receipt II: 97~/i Issued By:
Total Amount Collected: / ~ .7~
Job": q '5//4~
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