HomeMy WebLinkAboutPermit Plumbing 1994-06-02BACKFLOI,I PREVENTION DEVICE PEBM_IT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
SPrlTNGFIELE,
Offi ce:
INSPECTION LINE:
7?6-3759
726-37 69
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Job Location:
Assessors MaP #:Tax Lot #:ar2F>
0wner:
Address:Phone #:
City:State:Zi p:
Backflow Permit is $15.00 + $0.75 State Surcharge tv fgs .
Contractor:
Address:
State: ZiP:
Construdtion Contractors Registration #:Ex pires:
e
By s.igning this perm'i.t/qpplication, I ugt99 to call for an inspection once the
backflow prevent!on devitt rras neen ins[,al'led and'is visib'le for inspection
iiz6-iiog5. i aiio state that oii information on this app'lication/permit is
correct.
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S gna
FOR OFFICE USE
Date of Appl icat'ion : 6 ^? -?a
Recei pt #z / =t ;
Issued By:
,/2,7aTota'l Amount Col 'lected :
Job #:
225 F'ifth Street
sp.iilgiiliro, oieso n e7 477
-f2* 7a*z
Phone #:
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