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HomeMy WebLinkAboutPermit Plumbing 1994-6-3 :, .. 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: \o~Or) ~~~ (j ) Tax Lot If: ) Phone 11:\44 .\\r!o\ _ _' Zip: qtrT'fi Backflow Pennit Contractor: Address: Phone II: City: State: Zip: ,j Construction Contractors Registration R: Expires: 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. " CdIkY ~d/Jp0 ~ignatre, - j!/AU7~; ~ /?C1// rr F .~: . FOR OFFICE USE Total Amount Collected: to .5.Q+ ... Job H: Issued By: ~\Oll ) \\O.ao ' - ~\O Date of Application: Receipt If: \~\~f)