HomeMy WebLinkAboutPermit Plumbing 1994-7-8
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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: 7,26-3769
Job Location: {,fo((-b70 ~AI h
.Assessors Map U: /7--0-:3...:;z:-z.-4/2 Tax Lot U:
Owner: ,,} "dI~ ,.../"... Af /Y) p11r-l..fkY"\
Address:JS.lt;' V~
City: E,"11AL1 , State: "If
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Phone II:
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Zip: 97'10';
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~AflJd ;I' 1A/VI~r'
Address: sl( ~y-I Mq.Af,~ f<d
City:~.IA"1A.. State: iJ t1
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Construction Contractors Registration II: h::l. <;r I
Phone U: 7'17 -.r9'1b
Zip :..!i.L'I 05
Expires: ?' /3'/9'-/
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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Signature ~
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FOR OFFICE USE
Date of Application: 7-f!?-9~-
Receipt II: /-=?g~ Issued By:
Job U: q Y/~(*2.....
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Total Amount Collected:
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