HomeMy WebLinkAboutPermit Backflow Test 1994-8-3
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BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
Job Location: J ~Co<../ I1J. tJ2.()\ Yl~\+-
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Assessors Map 0: l .r '-'"'
Owner: }\.rO\ II<'€. 'f:::.e... ~yn CVYL.
Address: J roro \...j ()J. aLu \ I("\Q \ +
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225 Fifth Street
Springfield, Oregon 97477
City:
State:
Office: 726-3759.
INSPECTION LINE: 726-3769
Tax Lot 0:
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Phone 0:
7Y6-77S4
Zip: 97'-177
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Backflow Pennit is $15.00 + $0.75 State SurCharge"'-:?~ AA..w l' ~[. ~
Contractor:
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Address:
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State:
City:
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Construction Contractors Registration 0:
Phone 0:
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Zip:
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Expires:
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.
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FOR OFFICE USE
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Date of APPlication~"""~- C\ L~
Receipt 0: \ "\ 9CJ::) Issue'd By:
Total Amount Collecte~ \ ~ ~O
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