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HomeMy WebLinkAboutPermit Plumbing 1996-3-18 BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD . BUILDING~SAFETY-DIVISION \225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 ---------------------------------~-:::~----------------, ----------------------- JOB LOCATION:', A\)C\~ \'i l\\\\f J \ [\f'e ~ ' , ' .. ASSESSORS HAP t:\\ ~,:).lS\~ - - TAX LOn: \\'\u~l) O\INER: ~ \f)'(N\\\\\ ~ \\\\\f\f\_t \'j)'0f~ , , ADDRESS:_ ~,C8~, ' k~'\\f\\t:" J () f\e 'PHONE #:IL:l4\ 5., CITY: ~('(\ tdCl STATE: Fir€C~Of\. ZIP: C\lt17 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR:. ~ ~ee. _~ ,. ADDRESS: CITY: PHONE #: j ;. ;.... , .t, ,,~,"'l' ; .~ " ... .:~ . . ~'. STATE: ZIP: . CONSTRUCTION CONTRACTORS REGISTRATION #: EXPIRES: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769); I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS CORRECT. ' ' ~ ~7/~...---jJ51A~~ , lJ . '.. . . DATE FOR OFFICE USE -----------------------------------------------------------------~~----------;:;;J\ DATE OF APPLICATION: (; . \8. q /) J. ~A. JOBj': C\ \rQ3 0 \ RECEIPT ft: t\\)~e-- . ISSUED BY: IJ \j~ . . TOTAL AHOUNT COLLECTED: lo I ~) -----------------------~-~------------------------~--~-------------~~----------- J' ''-,,-,