HomeMy WebLinkAboutPermit Plumbing 1994-6-29
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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: 2 Z. (?'o l1"ft... .'~ I.-....t
Assessors Map II:
Owner:M,... "t- A,s, .B y.\ --.~'"
Tax Lot #:
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Address: 2..z.~() 80"\1'\ ,e..
City: -:\~ ,.:....<t1.'e-t.L
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Lq,_~ Phone #:
State: O~.
Zip: 97'f7'ir
Backflow Permit is $15.00 + $0.75 state Surcharge
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Contractor:
-Sc~e-& kl./S
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Addres s : 1ft) b >lod <.-'I(.e...,. ?:;;.'e
City: -S p "'~ +.,,_ (c/
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Construction Contractors Registration #:
L,....,/. 5" c.,,-Oe
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State:
Phone #:
7'flf-7f 3 t:)
Zip: 974-7'1"
Expires:. r;/3( !<r4
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/ Z./ 70
By signing th'is 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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Signature
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Date ' (
FOR OFFICE USE
Total Amount Collected:
Issued By:.
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Job #: 94..A 9/_/
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Date of Application: ~ -2;-J ie/-
Receipt #: ) 'S ~ 77