HomeMy WebLinkAboutPermit Backflow Test 2001-7-10 (2)
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BACKFLOV 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: 93[' Ro)fKJ)5L L.{/ {fI';Nt;!if4? &jL 71~jl1
.' ASSESSORS MAP II: 1< /7,.-.,<:' 7-"4'~ TAX LOT #: /r:J Y"Da
O\INER: RO~IIJ(!J a. /L! /l-f}-5{;;;c;f:' c.;t:.~ <:
ADDRESS:
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PHONE II: 7(/7-.1/ ~2
CITY:
STATE:
ZIP:
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE)~
S~ M.1AJ>Ct1/E
ADDRESS: rY 3 57.f iF cio{ffi.t iJ/) LE R p
CITY: C5..ftf./Ea.. STATE: (Hi..
CONSTRUCTION CONTRACTORS REGISTRATION #: LC15 '# /2'l1}c,C
CONTRACTOR:
PHONE II:
J'fJ'~d 1'/'1'
ZIP:.z.P~/-.
EXPIRES: :;-) / ~ crOc.
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV 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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'SIGNATURE
DATE
FOR OFFICE USE
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RECEIPT II: b 0 7 gt ISSUED BY: " ((' ~ Cl;;a
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TOTAL AMOUNT COLLECTED: =--- C'J .. "*
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D .. C:O
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