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HomeMy WebLinkAboutPermit Plumbing 2001-4-9 I' ! '. .' J;W'C{.Y.efys W~CJllle. 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: L/ J- c.j ( to ,~ lUJ'J1..{ o . /AK"7\' , ASSESSORS MAP #:/9" 8d- d)-- ;;;. if i\101f~X.:LOT #: (ffl (/ V 9RN,E~:_ hA ~'T-~d'(" (~ss:~lf-,I'W7~-h~\(P.I~E..IFTH,E~~?~C'J . . . - ....f. ...:J"ll '.",'.' AU I HUH1Lt:.LJUI\l}'t::n II l.J1 1...1 ...", ,......,."_ I ,,1~'6RESS: /4-/10,.' W ~,.f:hc:wv1-;S{5Y.. e.O (y'\h,1tPHONE:r#,:hG.~,~/~ .NZ(P~B'~.gou 0llIIL~.llVj . _}~~ '. rCITY:tJFj)lfW)(f\IJ'~j',:~~~0.0I;;~~',J STATE: (109JY 180 DAY PERIOD: ZIP: 974')...Cj 0090. \..", " . I -.1 ,n: ,-,,'- II' ( ,-,..' ,.. ca li'L .1 ' , , .....'("r, BACKFLOV PERMIT IS $15.00'+ 1~'b5 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 ,.... ~ CONTRACTOR: ~[ -""="u .:L:.~ 1~:)K#U?kY~~ ADDRESS']'b,'{).' ~l~"~..,.orril ,44>12.. PHONE /:.$f+3 5liS:-'#f-lIJS CITY: r J Co~ STATE: (()Q f) . ZIP: 7/<;0 ~ C~NSTRUCTIO? CONTRACTORS REGISTRATION #: 1.3 J 9 '0 ~ EXPIRES: !.?/:Z '3/0 '(, ( , 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. ' /cS,/~~ SIGNATURE '.. 'c;Jc? )0 J DATE' 1 FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 4~07 -01 JOB #:C)(J t)t!Jo7Y 6 J RECEIPT #: LjJJ7Y ISSUED BY:h . maMa"h TOTAL AMOUNT COLLECTED: /(0. ...,'1!)