HomeMy WebLinkAboutPermit Plumbing 1994-7-21
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759 .M
726-3769 T
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Job Location: 2. 340 L0c...L D;',
Assessors Map U: Tax Lot U:
o~ner: 'i.' -9\<L~'\ ~ t~U.uO'll ~
Address: 2- 3 If.D' L.Dc..t.. /Jr, Phone g:
City: 5,C)~'\f" id State: (I,.t,
Zip: 7'747-0'"
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Backflow Permit ;s $15.00 + $0.75 State Surcharge ~~
'contractor: 's-/...(s-K..
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LG.",-dr-r 'Y'
G~J r"'~;r<-j,b~
/./,,,,,c, Phone U: 7 t/-(j.- 7 I )'5
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Address:
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State:
v
Construction Contractors Registration H:
/2/ 7D
Zip: '} 71/-7'7
Expires: '2'/;/ )94-
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" City:
By signing this permitlappl ication, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). 1 also state that all information on this application/permit is
correct.
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Signature - ~
"/ /'2. i /94
Uate l .
FOR OFFICE USE
Date of APPlication:~.cOLl.~ ~. Job U:
Receipt U: \4.\'01 Issued B:/.:_7)\ff'\ )
Total Amount Collected: \\0:70 '
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