HomeMy WebLinkAboutPermit Backflow Test 1993-7-19
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SPRINGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: ,')1'-/ :tf'lvc...dlh-'~
Assessors Map II: 19.()~Od.-:l\. Tax Lot #: bl~O()
Owner: '"Rnb \.-~ I~~: Ph
Address: I ~ 14- j-JW"'-.dUA ~ Phone #:
City: ~'~5~ pJ!.rO. State: (JR Zip: '114-:7"/5
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: (')() ~ ,-... 'Lv</ ~r' -:UA~
Address: -::1,-:1k s.-JL'",,",~"' Lv>
City: C;..u~o. State: oR
Construction Contractors Registration #: c:::; II)
Phone #:3!:f2..- /~
Zip: QJt..J04
Expires: I),,) 1'14
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: ,) \01 \0-:2,
Receipt II: '1S6\o Issued By:
Total Amount Collected: ~'S./S
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Job #: CJ 3. JT)<. C)
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