HomeMy WebLinkAboutPermit Backflow Test 1993-8-9
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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:
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City:
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br;),/,,^<,- ~ L{I~ State: OA.
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Tax Lot H: OLly 00
As s es sors I~ap II:
Owner:
Address:
Phone H: J'-f/~ _ ?'(...,0":l.,
Zip: 9,'-07
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: \ A It.~d /lJJl). -;RO/nd/) ('.0. LJ :..lOc
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Address: III () 'fC{J)p~ 81"\, Phone
City: 9.-u'OLvo.fl.. State: ()().,
Construction Contractors Registration II: I OLf J?.
H: (o'K&J D0::l'-L-_
Zip: Ct ') o.fo'-l
Expires: 51""::./ ~LI
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). ~~lso state that all information on this application/permit is
correct.
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Date
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FOR OFFICE USE
Date of Application:
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Receipt II:
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Issued By:
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Job II: OJ~ II h q
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Total Amount Collected: