HomeMy WebLinkAboutPermit Plumbing 1993-7-1
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
,CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Stre-et
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
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Assessors t~ap If: ~7 2/ /0Ct:JU /~~ Tax Lot If:
Owner: Ei'a,'/A-f ./: ~/u ~
Address: '01 cP-.13 ~H""" p_ L..Ct~_
City: 9r; lAyh eJ,.)
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State:
Phone #: (:;-03) -<1- '7 f-.5?JY'l"
Zip: 9'tYrr
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Backflow Pennitis $-15.00 + $0.75 State Surcharge
Contractor: S e-I-F
Address: Phone If:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has ~e~n 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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FOR OFFICE USE
Receipt #:
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Issued By:
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. Job #: .~(;;, /
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Date of Application:
Total Amount Collected: