HomeMy WebLinkAboutPermit Plumbing 1994-7-6
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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
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Job Location: 2-33l/- (,..,.&l1f..... Dr.
Assessors Map H: t 1 D 7:J U:;oD
Owner: G e....<Z. 'Y f)._~ ,)e. L II> e. \oJe..'"
Tax Lot H: DOC( DO
Address: 233 <I- '-0 c.. ~.-
City: <:;4r,'.w ~."r.-I./
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IJ.... Phone H:7c.j.'f- 17<1-t.f
State: ()L, lip: '!7<f7Y
, Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
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State: oR..
Phone H:
Address:
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lip: 17t.f7.R"
Expires: "if.l 3'/ /7'1
City:
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Construction Contractors Registration H: ILl 70
~ By signing this permit/application, I agree to call for an inspection once the
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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.
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Signature
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FOR OFFICE USE
Date of Application:
Receipt H: ('37t I
1 - {,;; -0. cJ
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Total Amount Collected:
Issued By:
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Job H:
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