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HomeMy WebLinkAboutPermit Plumbing 1996-7-24 . . SPRINGFIELD BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: fl55 (.0. HM.l0u) . ASSESSORS MAP It: /7(,)~] 72 J OIlNER: So Dp.,\~<i r- \'E:.~ ~u...t>D\.... j , ADDRESS: I ~ q (") N . '4 'l IJ~ CITY: s,? Po. \ A)~ ~;~\~ ~l"\A~. TAX LOT It: l'\ \<;'1'.\l \cr: /o/2t) STATE: PHONE 1I.: ()R.C~(\~ ZIP: 3..2.:fjj BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. CONTRACTOR: ~ L.u\ N ~\ V ~." 'So p' \) M(l..., '\ "'" 1 ADDRESS: .-: 5 :l. 5 :\" ~ \J iN j R Q PI~ PHONE It: CITY: t:..U'1~r..)e: STATE: (\~Q{)"':) CONSTRUCTION CONTRACTORS REGISTRATION It: 1'1(" C\ 5 FEE) = $16.20 . c,~- 1<./'1L/- ZIP:~ EXPIRES: (~- 't:1___ 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. ' . ~/!o-1 A fl.,f AbIlA _ ATUr \. 1-. )..'1- 7& pATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 7-:Jlf 4 ~ RECEIPT u: 12 (,J (T'/:?( ISSUED BY: TOTAL AMOUNT COLLECTED: \ {fo' . )'/J JIM JOB U: 9fd'Jqq 7 1 -- - --------------------------------------------------------------------------------