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: 2- 39 f L OCI-J
Assessors Map U: t..,r /"!)- ~r~~, Tax Lot H:
Owner: a4J~/Jt;n- Viii /Jl//7#
Address: 2< C)? ,L~c...l-I Phone U:
City: ~Ur"I~t(jC:s. LJ') State:-DJ( Zip: &J 7'176-
Backflow Permit is $15.00 + $0.75 State Surcharge ~~~. y 5'
Contractor: 4u7f9n1A-n/' ~Il/J< I ~i K~J''? (' v"C
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Address:_liPS-7 ;?t}"'~I"'T j)J~_ Phone H: uB7~ D '? -=l?
City: Ct/GEIUe:- State: OK Zip: Q7'1o I
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Constru~tion Contractors Registration #:~ Expires: ~~9~
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 Appl;cation:--6=-/,P"':.9'J".
Receipt #: ,0 ~ _<e::- Issued By:
Total Amount Collected: ~~. ~
Job #: ~~~~ '7
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