HomeMy WebLinkAboutPermit Plumbing 1994-6-14
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SPRINGFIELD
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 Loca t ion: '? L-( to l.t.
Assessors t~ap If: /7c7 3
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Tax Lot H: - CJ~~O 0
Owner: ' M{. ~-t'lA
Address: cl...10lo
City: 5(X'\~\ \ \ 'e.\ cl
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State:
Phone #:
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Zip:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: 00....5\.. ~ ~ 1- If I( \. 'l a....-\- '--c:.. .
Address: ClLLo 5v-..,^^-~'-- Lc -,
City: ~1.e.....e- State: OQt=
Construction Contractors Registration H: S-ll'1
Phone H: ~'-() -{ \{~ '""L,
Zip: q 1 '-{o <-(
Expires: //?;jiS
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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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'Date
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FOR OFFICE USE
Date of Application: ~ ~~~~~
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Receipt II: (3L/[~, 'Issued By:
Total Amount Collected: /~ ._2.0
Job #: 94~57J
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