HomeMy WebLinkAboutPermit Plumbing 1994-8-8
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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
Job Location:--101 - t'JoL/ AI C/nJlPr/eal L<"
Assessors Map U: /70? -:22 ;;;; I Tax Lot U: r<?9S-cro
Owner: \;nv>rj.,j Va..,,'/t'r zande?J
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Address:1L'X- )Ol1Y1f' Ht' Crt Phone U:
City: <;}r~ State: f?/? Zip: Q1<(77
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: f2 'W1 pro /r! h. a YI j s: c a O(J
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M 4 f!>pu/(, Rd
State: () If
Address: '3 t{ Y: f( /
City: E () 510)1 ()
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Constructlon Contractors
Phone U:
Registration U: (f) 2<;(1
Zip: 97'1() t.,-
EXPires:-!/3' 1/9..:L
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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FOR OFFICE USE
Date of Application: ~~~~5s~
Receipt U:_ /4 2.....1 ') Issued By:
Total Amount Collected: Jh :0
Job U: 9efl 21)-9
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