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HomeMy WebLinkAboutPermit Plumbing 1982-3-31 8ACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD 8UILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: t2-~DQ '[;1-- Assessors I~ap If: \ ( 001../~\ ~ Owner :"'~.())~ ~10 ~l ('" Address: 12$D U sJJr-- City: (~"":f d" -<-\ , Tax Lot If: o)\6D , Phone II: '''fl.(-7 ~,(?L!LfC1 I Zip: (} 7 L(~77 State: De- 8ackflow Permit is $15.00 + $0.75 State Surcharge Contractor: f,w It.lV Address: Phone II: City: State: ~ip: Construction Contractors Registration II: Expires :. ~ signing this permit/application, I, agree to call for an inspection once the backflow prevention device has been installed and is visible for inspection (126-3769). I also state that all information on this application/permit is correct. ' Sigl1~ /:('J~, , / :3 -- 3)- 8'z, Uate FOR OFFICE USE Date of Application: ,~-~'I ,..--,'z., Receipt fI: ~"'6- '-f(~0 Issued 8y: Tota 1 Amount Collected:. l 6 .1 ~} Job #: CVV\..N'- 0 qff I & 1 --'"'