HomeMy WebLinkAboutPermit Backflow Test 1994-6-6
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BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELO
BUILOING.SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location:
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Assessors Map H: /7C7)A -S c( 'J--2-
Owner: ~VJI' /1l..J-?'-::1r-U/-./LL-
Address: frx/ -. :;::;;////,/.I;'A U
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City: ~..e-IA1"Ft'~W'"/ State: IJV
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Tax Lot II:
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Phone n:
Zip:
Backflow Permit is $15.00 + $0.75 State Surcharge ;;- CJ,-t,sA-r)4$/..o;zce-
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Address: t'7oif 7 '!01f-7.l11"'1 ~l Phone H: -;7'/f' -7 -1,Z~?
City: \i;L'~;':J,fN, J),/-L- State: fJE- Zip: 17.1/'=;;;"
constru~tion Contractors Registration H: ~~~~;'~EXPires: /~~~
Contractor:
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
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"Date
s;.griature
FOR OFFICE USE
Date of Application: 1.,/e,n4
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Receipt H: /~Z2j Issued By:
Job II: 9~q
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Total Amount Collected:
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