HomeMy WebLinkAboutPermit Plumbing 1993-7-26
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
, Office: 726-3759
INSPECTION LINE: 726-3769
Jgb Location:
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Assessors Map #: ~r22- ;fI/~L>tt.F ~~ax Lot #:
Owner: C::::~~~4 ,#VT"/S/#
Address: ~~.
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City:
State:
Phone. #: ?t.J)..- lie::::> y~
~-?'_ Zip: ~?&Y/7
Backflow Permit is $15.00 + $0,75 State Surcharge
Contractor:
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Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
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.
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Signature' ยท
7/2'/95
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FOR OFFICE USE
Issued By:
Job #: cr?/<?9Z-
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Date of Application:
Receipt t/: 96 ~
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Total Amount Collected:
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It?- 75
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