HomeMy WebLinkAboutPermit Plumbing 1994-8-2 (2)
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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: (oq~c<- fo~5 /iJ rJItI/.Pf (ui If
Assesso~ H: (7 Z>~2-'}~1 :rax Lot H:
Owner: ,,\~ \ A.)~
Address: ( [15 J>e..b vl eX- 8-J
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Phone II:
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Zip: 97'-(0 J.
City:
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State: tJ{L-
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Backflow Permit is $15.00 + $0.75 State Surcharge ~ :3~ (,45)
Contractor: r:-~ t JJ.-iA ,~S 0-0,~
Address: '3LJ'ty I M{f\.+-!i\^OIW') ~
State: ('fy'L-
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Phone H:
7 ~ 7 - ;Yh{ (~
Zip: Cf?,-!oC:;
City: ~/\A~
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Construction Contractors Registration R:
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device ha5 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
Total Amount Collected:
Issued By:
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Job H: q 31 7D'"2.,
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Date of Application:
Receipt R: \ l\ ~ kG
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