HomeMy WebLinkAboutPermit Plumbing 1993-9-10
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: eoQQ4 P>W6PJt,L\"'~
Assessors Map #: {7oZ-":.:>S:?;~
Tax Lot #: 0400(..1 -
Owner: 'J'Ot0 P'-IHAN
Add res s : .p..o. '5c:))C'
City: f'.st-\"'~ <::\2.&.\1
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Phone #:
'14 I - 31~~
Zip: q1lr~8"
State:
O\L.
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~I\I\J\~,.JM~N '"B\l
l-AN-DvGtli>b 1:
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Phone #: 14/- "9(09 ::}
Zip: q,L{tS
Expires: '1/311C/tf
,
Address: (Qll f'!.. tOTf-\
City: ~\NGFH?t.D State: dj}...
Construct i on Contractors Regi strat ion #::118 :;.
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct .
~ '-11. cO j~
~gnature ~~~"
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Date I
FOR OFFICE USE
Date of Application: ""9 -10 -0 ~
Receipt fI: ( \.) 1-\ q Issued By:
Job #: q '?> 1 ~15
~ I\"~'
Total Amount Collected:
1e;.7S