HomeMy WebLinkAboutPermit Plumbing 1994-6-15
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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: Z37t:J L(!;/.J-J. '.*. "
Assessors Map U: &( U ~'5rrN' Tax Lot U: .
Owner: k"E j rt./ Kh' BE"'; ,J
Address: 2370 //:;c...l-J Phone II:
City: ~pr"JA//iRFLi) State: of<. Zip: P7J17B..
Backflow Permit is $15.00 + $0.75 State Surcharge T ~~ ,7""5
Contractor: 4'-t9 YY(A--rJ ( ~V'JJt)'<1 E,~ ?E'"p-i-Jill ("'fit.
Address: /65"7 /2)"((':;7 VJL Phone II: ro e 7- 6 z.~~
City: ~Oat3,uE State: OR.... Zip: tj7~D I
. Constru~tion Contractors Registration II: I /q e '-! Expires: 2-/ 'i <,-
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
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FOR OFFICE USE
Date of Application: ~~~,~~
Receipt II: / ~ ~.:;- Issued By:
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Total Amount Collected: /'~ ~~
Job II: ~e:rC)5:b=~
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