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
Job Location:J6-L(~.s-'1 eJ,p-r.~-L~
Assessors Map H: I ?'t:>~~;Z'%-'I2. Tax Lot D:
Owner: 1MA"'" e ..PoJ/Y) ~/Y'l
Address: fJ..(,7G" w~ Phone U:
City: ~. , State: (l) IT
Backflow Permit is $15.00 + $0.75 State Surcharge
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,Contractor: &'J/l.IJ#.d ~
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State:. <fJ /?
Address: ]'1 'l'i:/
City: BAA.JAu
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Construction Contractors
Registration D: 1oP..9:/
Phone D: 7 '/.7- J 'I 'f"
ZiP:2'105'
Expires: 11' /Jj h,/
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 applicat,ion/permit is
correct.
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Signature
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FOR OFFICE USE
Total Amount Collected:
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Job D: 9~P22""
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Date of Application: ?-I?-~ c.f .
Receipt U: l-:rg/3 Issued By: