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 #:
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PHONE #: '14tP.-41 J ~
STATE6f:F;7 ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: W \~SO(
ADDRESS: ~~O.. BoX
CITY: .r:;AJC:::-
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403 ~tf
PHONE #:.Jp, f;C} - 0 cr ?- L
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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
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: fo,., 2 -q 7
RECEIPT #: asqg~
TOTAL AMOUNT COLLECTED:
ISSUED BY:
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JOB #:Q7()6'1/C;-
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