HomeMy WebLinkAboutPermit Plumbing 1993-3-16
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SPRINGFIELD
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: 'J.,L;$'<'b ~TT'TV.,,:) c..... - 12cv~""'I' -:c~ ~
Assessors Map II: 1 } O~ ";l-;:). 'An Tax Lot #:' (')nCJ.jj
Owner: S It'~ - C!. C-ovP - t'1I\.~...... ?~~LL
Address: Phone #: 1-'2.,.~" '> 77 '-
City:
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State: Ob _
Zip:
Backflow Permit is $15.00 + $0.75 State Surcharge
Address:
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10 IQ<- II ~~
Phone #: wY(.;.--YI:&,(j
Contractor:
City:
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State:
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Zip: '17 'fC/;O
Expires: & \-::'0 \'1"":>
Construction Contractors Registration #:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention de ic s been installed and is visible for inspection
(726-3769). I also st t th t all information on this application/permit is
correct .
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FOR OFFICE USE
Receipt II:
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Issued By:
Job #: q4J2'7~
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Date of Application: ~-;I~~~
Total Amount Collected: /2;': ~
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