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HomeMy WebLinkAboutPermit Plumbing 1999-2-4 . . SPRINGFIELD " 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: to lr (, <- P:. r<, ft........ sf-. ASSESSORS MAP fi: \ 'I. () ).. n:s. \ 1 no ";1-KU TAX LOT fi: OIINER: T,' __ P ~ fk~.~ ;gENT, IQNf,,~~t>law re,g.U1res you. ~v ADDR1ro; , .:k>l vthefOaagqnp!'!ilY s:h PHONE fi: 74-11- 9Z 50 T61 0\. ',~I~- nt Those rules a{e-SelfOIUI NOTICE: " CIT~!l~:~~~~-~~.<tv.hm"~n OAR 952-001- STATE: 012,. _ n. .,_ ~.... I 'Zl',!Ip,: I/:'Tr.!ClI\\"!)RK 0090. You may obtai~~~\]Pi~~~~~::;~~~~ by ~~~:O~:;~~ ~~~-;R- THIS PERMIT IS NOT BACKFkQl\1I,$l\lu'1,,1~r.~D t l'dNtlti(i~a~$ifATE SURCHARGE) + $.45 (ADMIN. FEE)"~o$16'r20R numberlorthe Oregon I 'Y COMI"WNl;; U uH IS "o-:",~ ",~"" ~ CenteriU-BOO-;332-~344). ,." '_'" ~"p,~:") CONTRACTOR: i:>v~< 1{4... :s L....l5~V< --I- r~V','),f."'~ ADDRESS: ita 6 ~o ...,O+IJ. .A".A.... k""'"7-'''' 11_... PHONE fi: rJ/.L/,- 7/'35 CITY: STATE: 0(2., ZIP: 97<1-7'1 EXPIRES: '-/-...7' In , CONSTRUCTION CONTRACTORS REGISTRATION fi: b 331:> BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIllS PERMIT/APPLICATION IS CORRECT. ~~ SIGNATURE dJdev " 2../ <fir 1 DATE FOR OFFICE USE , DATE OF APPLICATION: ;)-4 ~Cj c;- RECEIPT U: n.3 )..--;1< 7 ISSUED BY: TOTAL AMOUN~ COLLECTED:, \t \ L? _ ;rLJ'" --,----------------------------------------------------------------------------- JOB fi,c,0o 1 (po '{\ _ .{\(\O....{ ..k~J ,A.:l --------------------------------------------------------------------------------