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HomeMy WebLinkAboutPermit Plumbing 1995-3-23 r/ 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'-;> _..- ~, & / 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/~ , /'.. ..- CITY: ~_"J7-dl STATE: CONSTRUCTION CONTRACTORS REGISTRATION #: (!J/? ~33o 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. ". ' 'I: ...... ~~f~~ S'.rGNATURE ~ / ~3~2S-~r; DATE FOR OFFICE USE DATE OF APPLICATION: (? /}.:..) /p r ( I RECEIPT #: / ~ 7/ 'S ISSUED BY: ~;, #: 171JZ72 ,.. TOTAL AMOUNT COLLECTED: /~'20