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HomeMy WebLinkAboutPermit Plumbing 1997-6-2 BACKFLOY 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: J}t)7 qUW ~L--r " ASSESSORS MAP #: 170 '3 :20 L( / If OYNER: M~r;, P12DC, \ W ADDRESS: l7~/ &OI\N AvI CITY: SP2\tJ&~~D TAX LOT #: /~oo PHONE #: '14tP.-41 J ~ STATE6f:F;7 ZIP: BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 t. CONTRACTOR: W \~SO( ADDRESS: ~~O.. BoX CITY: .r:;AJC:::- LANo, 403 ~tf PHONE #:.Jp, f;C} - 0 cr ?- L " . STATE:Ot~ zIP:Q74CJ4 Sj{)3 EXPIREf-'U7 CONSTRUCTION CONTRACTORS REGISTRATION #: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS CO~ECT. v~ SIJGNATURE ~-z,-11 DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: fo,., 2 -q 7 RECEIPT #: asqg~ TOTAL AMOUNT COLLECTED: ISSUED BY: /(0 LJ-Q IlL--- JOB #:Q7()6'1/C;- \., - '--...