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HomeMy WebLinkAboutPermit Backflow Test 1990-10-24 r' . . 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: 7D7 ~rn1l, (].LmJll lD(( Assessors 11ap II: /7,..,::2-? -, ~ ' I ~ v ~, c-7 Owner: 1...lJc#41/l:.R 'f? A fZ7')/P.R.S Tax Lot D: /) ~ ::S6i) Address: !/qq I.J -r&lf~JI) 1 Phone #: ''irl-9/dD State: ()l<.E&OAI Zip: City: $.L-lC-€AJ& Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: f) W1-^-JLV Address: Phone #: City: 5tate: Zip: Construction Contractors Registration #: Expires: By signing this permitlapplication, 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 . fi~ 7Jt~>- -/ Signature - /o/c:;J.<-Jho Uate FOR OFFICE USE Date of Application:{n ~:l.L/ -17) Receipt #:~1J Issued By: Total Amount Collected: {;:J 7 C, v Job D: O~ Y67J f?00