HomeMy WebLinkAboutPermit Plumbing 1994-1-13
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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:
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Assessors Map If: b(')(')(")~(")On
Owner: )~~. ~_ ~ r~/lt/lAAr~~
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Tax Lot #:
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Phone II:
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Zip: 0;, LfS-C:-
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: rAA A./t))r-("\I/\ +; l_~'\ .V\j(J.Jf'\)
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Address: \(....,~7 ~AA/J/)pA. 10".
City:" C(LAcr~ 0 State: n Q
Construction Contractors Registration II: II Lt 'XLI
Phone #:
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Zip: OJJlf6/
Expires: d I;). s<} 0l..f
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
Date of Application:. \\ 1'J, \qy
Receipt #: \ \ ~S(r' Issued By:
Total Amount Collected: -.$ 1 ~ J S
Job #: Cj ~ I on to
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