HomeMy WebLinkAboutPermit Plumbing 1994-5-31
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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:
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k/<7?A/ .#,(M,e-. Tax Lot #:
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, Assessors Map II: ~ /?
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Owner: -~?_/ II, ""L
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City:
State:
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Zip:
Address:
8ackflow Permit is $15.00 + $0.75 State Surcharge
Contractor: _C ljj,~ LN.LC<V'JR J
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State: 6;('
Address: 1./6t'~
City: 5iJJ/
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Construction Contractors
Registration II: ~_3_?d
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Phone #:. 7'7'7- 7S/~
Zip: '774f?'f;!
Expires: 2-.;fq:.. 9t"
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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Signature
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FOR OFFICE USE
Total Amount Collected:
I ssued By:
/to _ .2...0
Job 1/: qkJ 79 r
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Date of Application: c:;- '3(- <34
Receipt #: / :5 0 ~.r