HomeMy WebLinkAboutPermit Plumbing 1991-08-05Y OF SPRINGFIELD, OREGOryqr
BACKFLoltl PREVENTIotFoExLlt rHliit APPLICATI0N
sutl-oil'lG sAFETY DIvISIoN
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Offi ce:
INSPECTION LINE:
726-3759
7 26-37 69
\Zc.: tifth Street
sprilqii;to, oreqon 91 417
Job Locat'ion :
As s es sors ap ll:
Owner:
Address:
C'i ty :
State:
FOR OFFICE USE
Tax Lot #:
one #:
Li p:
Zip:
Exp'ires :
It
Backf low Permit 'is $15.00 + $0.75 State Surcharge
Contractor
Addres
State:
City
Construction Contractors Reg'i str It
Bt.il!:;^i,.:ll:,i:;,.]:ii?B'iii',1!, iliEi::i:'li'hlll;lll.i'll.il;lnii:ll'
(726-3769). r oit'o tIiit-iltot all information ot
correct.
Date
ure
Date of AP
ReceiPt ll:
p I i cati on
Job #:
Total Amount Collected:
ssued BY: