HomeMy WebLinkAboutPermit Plumbing 1996-5-6
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SPRINGFIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING.SAFBTY-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 II: /7 n2, 'J L/ On
TAX LOT II:I"YJ7-1J..7.
OIINER: '-r; ..""
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ADDRESS:..2..S..? 'I. ~.....I If.. . I-..
CITY: < r---:J \:.- \ 1
PHONE 11:_7'11. -:H. ~ "I
STATE: oR ZIP:c;.-''iJ7'
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
CONTRACTOR: ~~.
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ADDRESS:
CITY:
PHONE II:
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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SlGNATUR,t;
DATE
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FOR OFFICE USE
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DATE OF APPLICATION: 5- 0 -q ro
RECEIPT 1I: '7,':2, q ( ISSUED BY:
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TOTAL AMOUNT COLLECTED:
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