HomeMy WebLinkAboutPermit Plumbing 1995-3-23
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BACKFLOW 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: ;JO:JO '8/E)/}d1-I;E ~.
, ASSESSORS MAP #: /103. 4 S I 2-
OWNER: . fV1 p( M 1/
ADDRESS: fl2 0 --2~ /~Y1'-;> _..- ~,
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CITY: ~/)..,t~/ STATE: 6;:(
TAX LOT #: ~c?J 00/)
PHONE #:
ZIP: 9'74--' 7'5"
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CO~CTOR:_gje-~4> ~C;C..~ JJ/'/~,(,i
ADDRESS: <~2..>6'9JO ~h/LZ.~' #,;;,V..../ PHONE #: '7?7~ 73/~
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CITY: ~_"J7-dl STATE:
CONSTRUCTION CONTRACTORS REGISTRATION #:
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ZIP: c; 74'79(
EXPIRES: J-2'?f.96
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 PERMIT/APPLICATION IS
CORRECT. ". '
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S'.rGNATURE ~ /
~3~2S-~r;
DATE
FOR OFFICE USE
DATE OF APPLICATION: (? /}.:..) /p r
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RECEIPT #: / ~ 7/ 'S ISSUED BY:
~;, #: 171JZ72
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TOTAL AMOUNT COLLECTED:
/~'20