HomeMy WebLinkAboutPermit Plumbing 1994-6-3
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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
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Job Location: '2.-~5 \ Loc:::.-\4
Assessors Map II: /.....;>7' "5"~,.l1/~P-C~~ ~Tax Lot N:
Owner: c.. \.,F\
Address: Sc Dhone II:
City:
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State: &:l.J'
lip: 9,,-\ TI
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Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: L~~,,\.c...- \v-(""\~o.-+t~
Address: '2-t:-S"2- vJ ~ l\o..~ ~\Ol Dhone II:
City: ~..!.li;' ~ll'- -E..,...x;.,-<--<-.e>.-State: ~
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Construction Contractors Registration II: leA '\
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Zip: 'l'J "1..0\
Expires: de...>\- ("fq'-(
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.
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Signa1:'ure l
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FOR OFFICE USE
Date of Application:~- -=3,,~t::/
Receipt II: 1-:;/9/ Issued By:
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Total Amount Collected: ~~,:?~
/!7b II: q~~/:>
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