HomeMy WebLinkAboutPermit Backflow Test 2000-9-20 (2)
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SPRINGFIELD
BACKFLOII PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225' FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: '8-:21 A?v~L a /_
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" ASSESSORS MAP 1I: 17D J z.. "3 c..r ~
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ADDRESS:
TAX LOT 1I: 0 2102
PHONE 1I:
CITY:
STATE:
ZIP:
BACKFLOIl PERMIT IS $15.00 +1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR: I-IILh;r,,,,( 7449....h.._ F .i/!l",#s~/,--
ADDRESS: .Jir::l?.C ~/ /f1,;~d,.("~~ .1.../ PHONE 1I:
CITY: 1/:,....,......779 STATE: .9A!
CONSTRUCTION CONTRACTORS REGISTRATION 1I: / /'3 ? '2
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ZIP: 9''>$/8''7
EXPIRES: <;--Jt9-rP/
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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DATE'
FOR OFFICE USE
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DATE OF APPLICATION:
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ISSUED BY:
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TOTAL AMOUNT COLLECTED: