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HomeMy WebLinkAboutPermit Plumbing 1996-6-7 '- . '. --- .. .: . .- . .~. ~ h .--.,.. 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 -------------------------------------------------------------------------------- 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 #: (J~ _ 007oc:;_ 7~ 7-J?> ~rL ZIP: ~ 74"7 ? BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.~0 CONTRACTOR: ,..-,MJA Jf2.r? 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. ~~~ DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 7?ab /.d I..,..-- JOB~: 9' '3Ocpsf RECEIPT #: 7j ~ :3# ISSUED BY: ./r ~ TOTAL AMOUNT COLLECTED: / ~,,20 --------------------------------------------------------------------------------