HomeMy WebLinkAboutPermit Plumbing 1993-8-10
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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: '.2,e:;~6 ~~~/~ ~ ..
Assessors t~ap II: / br. -:; /0~~G ~ Tax Lot II:
Ovmer: hLE?' / - '~~r / 5~y..
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Address:
Phone II:
City:
State:
Zip:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ,?1~7'-?~.#5' ~~'$~~
Address: ~&/~ /'//
City: F-4-~7;;'~Z!'v~~ State:
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....c.~'::trt,,:.L ;UI~ CO~,tractors Registration II:
L/j-~c~~:,,'
Phone II: &?q,5""'~rs'?
/9;:q"'. Zip: q 7~6
//89:S-- Expires: /-"5/-99'
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
cor~ct .
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Signatur~ u ~
j,ff-7 (() 93
Date -
FOR OFFICE USE
Da te of App 1 i cat i on: &7'0-'73":3"
Receipt II: ~~;r;r Issued By:
Tota 1 Amount Co 11 ected: t!'CS-" 7CS>--
Job II: 177 -"VT 9"?1'/8 Y
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