HomeMy WebLinkAboutPermit Backflow Test 1990-9-10
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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 Loca t ion : ~ '2 ~ PI) r +o.,V 0--
Assessors Map II: (7() ):?Lf z3
Owner: ~c).ful/..p -p., I-/vvvi --i!. ')
Addres s: Z/q q 2, 1J/J.Q.h ii/AS
City: ~i(~t/t^~ State:
,
Tax Lot II: .() U / q
Phone II: L( t L: -3./ --; I:- .
()fZ-.-- Zip: q 7t./()/
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: 0 J ::--h\'l/l P (LA (/1/1 (<1 i\/7 r
Address: '62--49. 1( PH +(A l?l1'}...[
City:.G-u..4R~~'\..L State: 01'2-
. J
Construction Contractors Registration II: 4 (q 7_ J
,
Phone U: 3t{.2- ) I L{ C;
Zip: Cf7'-/rJ/
Expires: Lf-z.7 -72-
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.
~?/7: ~?~
Signature ~
/,-./0' '-;? cf
Uate
FOR OFFICE USE
Date of App 1 i cat i on: 9' -If) --t? I')
Receipt II: /7;2-L/ D Issued
Total Amount Collected: It:). 7.5
Job U:
By: O---V~
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