HomeMy WebLinkAboutPermit Plumbing 2001-10-4
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225. FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: /b07 bod", 0. r<fI1At!JWd. OR- 17177
.' ASSESSORS MAP #: TAX LOT #:
OVNER: /2Ji el<:l(? ~/-rJ4u~i
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ADDRESS: tho 7 })1>t0~ tn
CITY: ,C'J1M1hdd
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PHONE #:
71/7 -33h.~
. ZIP: '17<177
STATE:
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BACKFLOIl PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $SI.7<;:
CONTRACTOR: CC)-k" Ldvrd('(~ 1/1A:1.. ... ....
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ADDRESS: 93?U, i2< 're.... M.
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CONSTRUCTION CONTRACTORS REGISTRATION i:
PHONE #:
STATE: . ;(j~tjtV)
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ZIP: 17t/</rf
EXPIRES:_7,......2%-02.
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.
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Ul:l:GNATURE
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DATE
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FOR OFFICE USE
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DAT~ OF APPLICATION:.. ./0/0 '1/-= t. ...
RECEIPT #: b lOI / ISSUED BY:
TOTAL AMOUNT COLLECTED: 51 ?...>-
. JOB #: .ot=.DJ09l-91
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