HomeMy WebLinkAboutPermit Backflow Test 1993-7-19
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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
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Job Location: 0/~ :}-r......r:AAJC<...d
Assessors r~ap H: (')",.1( l-^ '" 10+ ~"I
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Tax Lot H:
City:
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State: 01{
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Zip: qj'-Oi
Owner:
Address:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: 7'vv\u\o.fJrf ~o./Y'>./,j<::"O,...{H,
Address: ~Lf Q>? I 'YY\cctk.,..J<:" -Q--O. Phone H: ILl) -~04-h
City: C; .1-"',,1__0 State: ()Q.
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Construction Contractors Registration H: ~~ I~
Zip: 0/40<:
Expires: 'Ie;:>.,
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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Date
FOR OFFICE USE
Date of Application: -; /,~ 1<;-:>,
Receipt II: qSs R Issued
Job H:
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Total Amount Collected:
By:
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\$0B