HomeMy WebLinkAboutPermit Plumbing 1993-9-10
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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 Location: ~Cfq(o ,{)Llt%ElLtS
Assessors Map If: l7D?---?73?:J
Owner: JOfIJ+}Ttl-i\N N tf. YL
Address: f.O. BoX ICOl
Ci ty: (.Jill.- Cllet)l.
T ax Lot If: (Tt{ fo ?J r-./
State: O'fL...
Phone If: 1 t-(l- 316d
Zip: q,l{Jg
Backflow Permit is $15.00 + $0.75 State Surcharge
Address: 01l N. loTt\
City: S.;at \NG-fl\:U)
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Phone #: ~ (,11- J(Pq;)
Contractor: tHULl-ON I"'c.^J1:4 L
State: op....
Zip: cnL/.l~
Expires: ,fin/'lf
Construction Contractors Registration #: 518J
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.
Total Amount Co~lected:
I ssued By:.
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Job #:
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Date of Application:
Receipt If: t~ul4
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