HomeMy WebLinkAboutPermit Backflow Test 1994-8-4
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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:. L1 \ 01 1=0Y'SZ;-t11l'1o---!)V-.
Assessors Map II: llr 02..00?.:L.-- Tax Lot U:
Owner: CJI\.et ~ rJA.ot71 j)~4W
Address: L.P51 -r:~41N1O--PY Phone II:
City: >;ot-d State: (J)L--
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Zip :_Cf7Lf7'i-
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Contractor: 'J uv v.......v
Address:
Phone U:
City:
State:
Zip:
Expires:
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Construction Contractors Registration H:
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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FOR OFFICE USE
Date of Application:
Receipt U: l L\ 1X~ .
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Job U:
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Issued By: /iA/VV' 0
Total Amount Collected: (-I, (() 0