HomeMy WebLinkAboutPermit Plumbing 1993-8-13
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BACKFLo.W PREVENTIo.N DEVICE PERMIT APPLICATIo.N
CITY o.F SPRINGFIELD
BUILDING SAFETY DIVISIo.N
225 Fifth Street
Springfield, o.regon 97477
o.ffi ce: 726-3759,
INSPECTIo.N LINE: 726-3769
Job Location: /~57 g6/'?/Y'/~C~ ~
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Assessors t~ap #: tt:J7?3 ....17/~c E ~Jax
o.wner: [,~/n -I /~#~~ ~~~
Address: ;:j1f1; ~
City: .?'P r L-?::?
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Lot #:
Phone #: '7'Y6'-7"t:?,?&"
State:
h'/??,
Zip:
Backflow Permit is $15,0.0. + $0..-75 State Surcharge
,contractor:~~~/.~ .~~/A::i~~~' ,....
Address: 27;76. '"5'~~~~ ~... Phone #:
City:E~~CE State: ~ -
Construction Contractors Registration #:
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9 v;r - ?~:2..
Zip: 9?9~
Expires: 1- ~1'~9'
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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Signa<:je .
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Date
FOR OFFICE USE
Date of Application: gi-~-~.3'
Receipt ff: ~:3c::s Issued By:
Total Amount Collected: ?5:/~
Job #: ?J3/2a>-;>
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