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HomeMy WebLinkAboutPermit Plumbing 1994-8-2 (2) . . spnINCFI~LO . 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 ({lot; Phone II: ~~ :s Sfa 72- Zip: 97'-(0 J. City: ~~ '\.. State: tJ{L- " 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- &, 2J? I Phone H: 7 ~ 7 - ;Yh{ (~ Zip: Cf?,-!oC:; City: ~/\A~ ,j 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. ~ -4.. 7/ S::l"gflature "9 - z. - <jc.f Uate FOR OFFICE USE Total Amount Collected: Issued By: llP.z.Q) Job H: q 31 7D'"2., ~ Date of Application: Receipt R: \ l\ ~ kG g-7_4..f.