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HomeMy WebLinkAboutPermit Plumbing 1994-9-7 rl . - SPRINGFIELD BACKFLOV PREVENTIOij DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION o 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 JOB LOCATION: 2-~&.'7 S ' C--~}/LXLL7rF. L-tJ, , , . ASSESSORS MAP It: /76):S :::2- 2- 4 S TAX LOT It: O~.ER :~-rY.? /h(' /- d( C::A--u~~ ADDRESS: ~<gD 2.. / /~ d/.. p,z b.J _ PHONE It: CITY: .Eut:i4.:J6 STATE: c:;Pf', c?<1?~C;O ~ S~ - 5"2.7(". ZIP: 97-;1a 2.. BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: #/ ~/7E;Tt/ AJ,.e~rj; '77N ADDRESS: ,'4 /J /~]'x'" 4c; i }/ bvEJ?/.- 9 ?,5"-32./S ZIP: 97~6 '/ EXPIRES: <;i/.Ya-;/::>J I / 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. . PHONE It: CITY: STATE: D<- // S 72. CONSTRUCTION CONTRACTORS REGISTRATION It: , )S;o~~ , SI4~~ 1'-7-..9'7 DATE FOR OFFICE USE DATE OF APPLICATION: )>1 ~//cI- RECEIPT It: i# S J ISSUED BY: IF _ _2..0 TOTAL AMOUNT COLLECTED: ~ . JOB It: q1J3 7 g fl~ ,