HomeMy WebLinkAboutPermit Plumbing 1993-7-26 ,) 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: 2/'f?S- ~~#A//C U~E , /' Assessors Map #: ~r22- ;fI/~L>tt.F ~~ax Lot #: Owner: C::::~~~4 ,#VT"/S/# Address: ~~. ", . ~7r-l..-a. y' I' City: State: Phone. #: ?t.J)..- lie::::> y~ ~-?'_ Zip: ~?&Y/7 Backflow Permit is $15.00 + $0,75 State Surcharge Contractor: ~ f1/#F~ '. .f.1'_ . ,'.,,-/1- 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. .". .~ .1:.' :" ;' ~., ,:' ;' .,' /' / / ':J!4.. / I/I~ ',' f(/~ Signature' ยท 7/2'/95 Uate FOR OFFICE USE Issued By: Job #: cr?/<?9Z- .~~' Date of Application: Receipt t/: 96 ~ r 26.-7'5 Total Amount Collected: '. ~ It?- 75 .<Cl