HomeMy WebLinkAboutPermit Plumbing 1990-12-17
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:_ 531){ AS r~41
Assessors t~<1p If: J7D ~ 31--{ z.,Z--
Owner: :X:=-(.,~+v-.vc:B t ~oyY\ Q5
Address: 2ft 9 -:<) LA./\ e;:h')( /v...._~
Tax Lot If:. CX"-f 2,d)
City: P~-l^ c.,y~
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State:
Phone If: YY 5 ~3} 710
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Backflow Permit is $15.00 + $0.75 State Surcharge
Con tract or: J' H'D~ P IlAAA/\ b I'yL~
Address:-3.Z.Lj f' /L-e(/1+IAJD7")d Y (
City: ~-iAfi\,t/1;J- State:-,CY12...
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Construction Contractors Registration If: Lll qt.-I
Phone If:
Zip: q 7 cjrJ /
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Expires: 4 -ZL::!i.Z--
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/permtt is
correct. .
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Signature y
/~;:< - / 7- :9c::'
Date
. FOR OFFICE U.SE
Date of Application: 1'2..,-/7--1"0
Receipt If: r~q-tjg Issued By:
Total Amount Collected: 1?j..7Jfl5
Job If: ti()?) >lIt)!
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