HomeMy WebLinkAboutPermit Backflow Test 1994-5-3
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BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELO
BUILOING, SAFETY OIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location:lili..~O '\\ (J ~, ~\'IQ)[ )
Assessors ~"-\.- \"()33?J\4~'J Tax Lot U: roq \()
Owner: ,)( a^, t If ') ~~ (\0 '
Address: J 8DO f\\MO ~ 1)t1J 1\ I n ~one II: If --0-- J~
City' ~ ~ 1 tliCf iJrL";,,, (\Wi rn Iz;~,!J7't17
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor!\. .Dl01 (~ ) "-
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Address: ~
Phone U:
City:
State:
Zip:
Expires:
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Construction Contractors Registration H:
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). I also state that all information on this application/permit is
correct.
d~
rature,
S-J-9 Y.
Date
FOR OFFICE USE
Date of Application: t',,~ '\..~-C(4 (\ .)J~b U: Gf,~ l O()~...
Receipt H:_ \~ 5f(/cf-.. Issued By: \...7) (ffi /
Total Amount Collected: \ ~,~~ - ,