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HomeMy WebLinkAboutPermit Plumbing 1995-10-11 ~. SPAltliELD 'I BACKPLOV PREVENTION DEVICE PERMIT APPLICATION CITY Of SPRINGPIELD BUILDING .SAFETY DIVISION 225,PIPTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: 0 J 2- L I /JlJ -cY' lr.a. F " ASSESSORS MAP #: I, 0 ~ ;;)::L '-I:+- O\lNER: tA'/?E J/uO/V7A/lI ADDRESS: hl7 ..; /,?{/cr' ./_"'..{: ,?tJ CITY:~)1;-~J STATE: /_~ TAX LOT #:. 07 (J7TO ,. PHONE #:. ,-">./t' ZIP: 97'7?7 BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR:I)rt-,Fl L-AN/)'leJI.lr: ADDRESS: <2 t( ~ /J,j CITY:. EUj-r-nc CONSTRUCTION CONTRACTORS REGISTRATION #: PHONE #: STATE: ~L ~/q'7 '~ ~f?-9/9r ZIP: 9?'?tf'/ Y EXPIRES: JZ- 3'/- 7'5 , BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO\l PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. (?~ SIGNATURE I ., ~ 17"7 ( /~ -//-'T~ DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: / () - II - 95 RECEIPT #: () / 9;;;.25' ~ ISSUED BY: TOTAL AMOUNT COLLE E ) &. ')-0 . JOB ji: ,jJ, flA-/ ' 95cJ 77'/ --------------------------------------------------------------------------------