HomeMy WebLinkAboutPermit Backflow Test 1990-10-24
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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: 7D7 ~rn1l, (].LmJll lD((
Assessors 11ap II: /7,..,::2-? -, ~ ' I
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Owner: 1...lJc#41/l:.R 'f? A fZ7')/P.R.S
Tax Lot D: /) ~ ::S6i)
Address: !/qq
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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 .
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Signature -
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Uate
FOR OFFICE USE
Date of Application:{n ~:l.L/ -17)
Receipt #:~1J Issued By:
Total Amount Collected: {;:J 7 C,
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Job D:
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Y67J f?00