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HomeMy WebLinkAboutPermit Plumbing 1994-8-1 ~. .-. 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: '''-3759 '* 726-3769 BACKFLOW PREVENTION OEVICE PERMIT APPLICATION CITY OF SPRINGFIELO BUILOING, SAFETY DIVISION Job Location:29~6 ~G,y Assessors Map 11:~r /t:-/ owner:-k~ w-~Cc. S Address: :i.~6'. City: 7 p:''-ZJ State: P;;q . Tax Lot 1I:.~~Af/ffi. ~. Phone II: 726'5'/~~ ~.-?<' . Zip: q:; 9"""'>";> Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: .~~ ~~?'/;r;,/J';>~//~~ . Address: ohone II: ~~~Yo/ City: .State: ,j , Construction Contractors Registration II:~~~ Zip: Expires: 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 . I .'i?' )/ft-/ uatV 1/ / / FOR OFFICE USE Date of Application:_Ji?-/-'9'Y . Job II: ~~//<::/ Receipt II: /lj/"3'7? Issued BY:/? ~ - . ~~ /~V' - ~ ~,. , Total Amount Collected: ~. -;zc;> ,