HomeMy WebLinkAboutPermit Backflow Test 1996-9-13
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SPRINGFIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION:
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17 O~ 3'-1 d:?-
. ASSESSORS MAP 1I:
OIINER: -r;;,dol
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TAX LOT 1I:
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ADDRESS: 0.'-\0\ Fcu'V"'LA~C" '-"
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CITY: :", p'" ,'"" :J r,'~ / d
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PHONE 1I:
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STATE:
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ZIP: OItY"
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ~Of) ~~rl.I~V""'\
ADDRESS: q 60\ ~Y21---JCU 1{ PI
CITY: 5p,i,~f1<;Ln 0 ...JSTATE:
CONSTRUCTION CONTRAct6RS REGISTRATION 1I:
PHONE 1I:
Of2-
74(>- (/)0,70
ZIP: -
EXPIRES: -
-
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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FOR OFFICE USE
9-1""3-Of~
DATE
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DATE OF APPLICATION: '1- /3 - ~ V
RECEIPT 1I: OJ.-2/0& ISSUED BY:
TOTAL AMOUNT COLLECTED: ~ Ii p . '6V
JOB 1I: 9 ~03 ~/
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