HomeMy WebLinkAboutPermit Backflow Test 1993-7-20
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
22~ Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 2/7/5 FIA'm
Assessors Map #: /7(13 2.c; 12- Tax Lot #: /An/J7)
Owner: 5Tu fidA?6P
Address: 2/7~ F//p 77-1 Phone #: ?~7-?S~O
City: y~ State: /J}(f' Zip: '7>7-177
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: to /,(/;<i/M LAv,)r~~ / /~~ ~.A>1 J
Address: /7//J b'#-/./:,c/')R.
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City: WC:;-;"':;',,-TJ= State:
Construction Contractors Registration H:
Phone #: t;.~q -~724
~ Zip: <374crl
J/Jf'/'? Expires: S"~0-:L
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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). I also state that all information on this application/permit is
correct .
1(j~
'f- Sfgnature
7- ;2tJ--77
uate
FOR OFFICE USE
Date of Application: ;;/2~'J.7
Receipt II: "35"8'5 Issued By:
Total Amount Collected: ~5,7 5
Job #: 9,'S/CJ~9
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