HomeMy WebLinkAboutPermit Backflow Test 1992-6-10
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~FIELD
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: f6t;C5" M/Hr~cc ~r
Assessors l~ap D: L:::-7 -i; 2iY~ ,J"~~ u'F'?r-4"7<E:-S
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Owner:
Address:
Phone D:
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Zip: -:?'?Y??
City:
State:
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
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Address:
Ohone U:
City:
State:
Zip:
Construction Contractors Registration U:
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
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Sig~'Jre
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FOR OFFICE USE
Total Amount Collected:
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Job U: <920&21
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Date of Application: h -/~:?
Receipt II: ~e:;:.~ Issued Ily: