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: 726-3769
Assessors Map ff: /? ~?-2"'2-:r I
Owner: ,)a",^ 9-' ~ m~
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I State: o;r
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Tax Lot II: ~'9€--
Job Location: fo ~O - fa 1(~
Address: 1~?~
City: ~.J/Y\ 1.
Phone 1I:.-'J'<?'4 -II h ~
Zip:...21.>' OS
Backflow Permit is $15.00 + $0.75 State Surcharge
contractor:~ ~~
Address: '3 'I r~1 f1 ~ /?d Phone II:
City: eu..:,~ State: (1') I?
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Construction Contractors Registration 11: (o~ r?-J
7 >'7 -.f~Slb
Zip:31..1Y OS
Expires: r /3/ /91/
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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 an information on this application/permit is
correct.
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Slgnature tl v
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Date
FOR OFFICE USE
'1
Date of Application: 7,,&,,90/.
Receipt 11: J "? R>L'5 Issued By:
Total Amount Collected: /6. '2 e::;?
Job II: #f:J Y /tPl Y
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