HomeMy WebLinkAboutPermit Plumbing 1993-4-22
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SPRINGFIELD
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: ~~ L//,/P/'9cE ~ .
Assessors t~ap 1/: 17'-"<:)?-"2?-/2 Tax Lot #: ~
Owner: 566j(/-?(4 ~~/'3-'~:>'7 l
Address: 5;4'/;:,~. Phone #:
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City: 5?~ State:...-::?n. Zip: 9?Y:?>
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Backflow Permit is $15.00 + $0.75 State Surcharge )( ~
Contractor: ~ C~~.7 r' ~- ~
Address: /~ C;? 3 ~j:Y --:::< 2
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Phone #:
Zip: 9,7~./
Expires: 2. 7"<?~
City:
oJ:?-
#: 7/6'5I"S'"
State:
Construction Contractors Registration
By signing this permitlapplication, 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 applicationlpermit is
correct.
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Sigrfatur<€ -" .
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I-!J~- 7"~
Date
FOR OFFICE USE
Date of Application: tV-?-.Z.~"'35
Receipt II: ~<?2&> Issued By:
Total Amount Collected:S/. 5'c:>
Job #: <=7~')~
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