HomeMy WebLinkAboutPermit Backflow Test 1994-6-13
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SPRINGFIELD
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: 9~A .c.4..?;;t!f1,-,"#'7" ~L,
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Assessors Map O:-.t~r- 2~ ".p~.//..i~ax Lot 0:
Owner: 5ol/C-h"6/~~ ~~~i!5?f'>c:;.
Address: /7"'~/ ~~ ~. Phone 0: 7~ . a '9/6:
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City: ~~.A-/;> State: e:?'/9. Zip: q.') Y/?
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: C ~~~~ 0~,:"<J:?b5e:;...-;~,>~ ,?' ~#/?SC::-~ r
Address: ;t'Cj1?gr /~~C?----:.~hone U: '7 V:> ~-3'9%
City: F~~&- State: P..~ - Zip: -97Y~
Constru'~tion Contractors Registration 0:.-6:< ~/ Expires:?~ 9 y
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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). 1 also state that all information on this application/permit is
correct.
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Signature .. r r
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ate . /
FOR OFFICE USE
Oate of Application: ~-/""'J....9c..,.(
Job 0:
CJ-"3 c)B/~
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Receipt 0: /3-::r'?9
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Issued By:
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Total Amount Collected: