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HomeMy WebLinkAboutPermit Backflow Test 1994-8-4 --. .; .......... I ..f 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-- I OOL( Ox 71./'fo - ~7~ Zip :_Cf7Lf7'i- .' Backflow Pennit is ~~ . :J.:OS !:LL_r~.!,.,",.lj€__l. .'-4-:' (;% M''''''''J . -z. 106 elL--\' loW cJ.e VItft'S 01 1/0 DO .e.6-<:~ oj- 6~ 'STo,.+--e SUVC~ctL. T 3'?tJ od 1fA"... he... /~,n/l/lA"- (<.0.<.\0) ((.001 o. (bv). Contractor: 'J uv v.......v Address: Phone U: City: State: Zip: Expires: v 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. r~ (~Lk- Slgnature y <-( f<{ uat~ FOR OFFICE USE Date of Application: Receipt U: l L\ 1X~ . <l-L(~qd Job U: 4tJ 1,1 q7/ Issued By: /iA/VV' 0 Total Amount Collected: (-I, (() 0