HomeMy WebLinkAboutPermit Plumbing 1996-7-16
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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: :2 S (, t. - r:: ~r.~ :\
ASSESSORS ,MAP #: ] 7 n?' ~ Lf
OIINER: h~Iy.,~ ll~
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TAX LOT #:
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CITY: <;""r~~ "'rfl n \\
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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PHONE #:
ZIP: 97Y77 .
CONTRACTOR:
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PHONE #: fY9t-O'lnJ
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EXPIRES: S- J '7"7
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CITY: C0..3-k...< \ \\. .
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CONSTRUCTION CONTRACTORS REGISTRATION #: c;, 9/ If
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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DATE
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FOR OFFICE USE
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DATE OF APPLICATION:;- I (, ~ Cj <t:J .' JOB #: quo q V{
RECEIPT #: n:::i;)50K ISSUED BY: n. 6'Y\~c.~a.~
TOTAL AMOUNT COLLECTEo.J:b I {, _;)6
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