HomeMy WebLinkAboutPermit Plumbing 1994-8-1
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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:
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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:
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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 .
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FOR OFFICE USE
Date of Application:_Ji?-/-'9'Y . Job II: ~~//<::/
Receipt II: /lj/"3'7? Issued BY:/? ~ - . ~~
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Total Amount Collected: ~. -;zc;> ,