HomeMy WebLinkAboutPermit Plumbing 1996-6-7
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SPRINGFIELD
BACKFLOV PREVENTIO~ 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-~5~ ~.A./) p_(?
. ASSESSORS MAP #: ) 7n 7 :z ~ /"r ,,,>
OVNER: S7ei/~ /?77f.C,OC.K.
ADDRESS: 2<:::; S'~ 4~A ///._~ 0 PHONE #:
CITY: ~...Pr) STATE: af<: ,
TAX LOT #:
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7~ 7-J?> ~rL
ZIP: ~ 74"7 ?
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.~0
CONTRACTOR:
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ADDRESS:
CITY:
PHONE #:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
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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DATE
FOR OFFICE USE
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DATE OF APPLICATION: 7?ab /.d I..,..-- JOB~: 9' '3Ocpsf
RECEIPT #: 7j ~ :3# ISSUED BY: ./r ~
TOTAL AMOUNT COLLECTED: / ~,,20
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