HomeMy WebLinkAboutPermit Plumbing 1996-8-19
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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:
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, ASSESSORS MAP #: l~z. /? g II
OIINER: 'Hi. ,V'--1 1Z.11V\ e V\...( .....
ADDRESS: {OK-lll h I~ (~-C If' \.
CITY: <" ptO - - STAT,:
TAX LOT #:~.2.c ~ 0
PHONE It: 77J,... ~~ SLf;5L "
I'IvuJ . ZIP: 9 7Y77
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BACKFLOY PERMIT IS $15.00 + $.75 (STATE S(?:HARGE)
CONTRACTOR: ~ n .DV\,-e...r
+ $.45 (ADMIN. FEE) = $16.20
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ADDRESS:
PHONE #:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION II:
EXPIRES:
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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SIGNATURE:"---' 0 - - ~
Q-- 11---- q (,:
MTl ' - I C-
FOR OFFICE USE
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DATE OF APPLICATION: '(5,/ /P ~
RECEIPT #: 2. 2'9 /' / .ISSUED BY:
TOTAL AMOUNT COLLECTED: //h ..2.cJ
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