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HomeMy WebLinkAboutPermit Plumbing 1994-5-2 .' . .- BACKFLOW PREVENTION OEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING, SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759, INSPECTION LINE: 726-3769 Job Location: ~B~tC-. ~'{,~(',.-,,=,~ ~- Assessors Map H: /25'-'::::><~c:!:><-<"'<.... Tax Lot H: ~~~ Owner: #'~/~ 6:/?:?~~ ", Address: 7'~O ,N ~ ~~ ~ Phone #: ?~~ ~'7y City: ~~CD State:~. Zip: q'?C//8 Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: ~~~.~ Address: City: State: ,j , Construction Contractors Registration #: Phone 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. /~ /' -- '" Signature; ( 7 ,,,C_ , 5'-Z.'-9<f Uate FOR OFFICE USE Date of Application: 0"2--~.Y Receipt II: /25':)/ Issued By: Total Amount Collected: /~ 7.':;- Job #: 4~~~2.. ~~~. //