HomeMy WebLinkAboutPermit Plumbing 1994-4-25
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street Office: 126~I59.
Springfield, Oregon 97477 INSPECTIONLI~~~
Job Location: i-/L/tc? . j..~U s;,,iJIJI "
Assessors Map U:~'0. \ Tax Lot U: (MOO
Owner: iJ_ j u_rl -r:... J j LvI. ;. /J
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State: Of(.
City:
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Phone U:
726- ?/q--6
Zip: "17.?/17
Address:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~v}e- 111:s, L/ (G/-H-
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City:
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Phone U: 7t:/?/- 7/3'::
Address:
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State:
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Zip: <;??L/7c;(
Expires: ;( ,,;1 9-1(
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Construction Contractors Registration H:
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:
Receipt U: J'2.~JZI
Total Amount Collected:
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, Issued By:
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Job H: CJ4/).)/?
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