HomeMy WebLinkAboutPermit Plumbing 1993-8-10
BACKFLOW, PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 7t? 7C/ ~~~~/d;- ~.
Assessors t~ap If: ~7 fiT ~~~ ~r Tax Lot If:
Owner: ~?/5~&!>,/q~'
Address:
Phone #:
City:
State:
Zip:
Backf10w Permit is $15.00 + $0.75 State Surcharge
Contractor:
7< #-~/')~~'5 ~~c~~
J / , /' .it:..'" - , ~ . ,
Address: ;;:?~ ~~' ~/ Phone #:
City: ;f::~~~~~;;:r~' State: ~.
//g7.'::::> '. Expires: /-?/--:Y'r
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Zip: q'79'VC
-Cf:n!:~;j::i9-R' Contractors Registration #:
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By signing this permit/application, I agree to call for an inspection once the
backf10wprevention device has been installed and is visible for inspection
(726~3769). I also state that all information on this application/permit is
corr, ~ct.
iL ~~~~~ -
SignatUte ~ v -
;/'K--r /0
Date ..
75
FOR OFFICE USE
I ssued By:
Job#: 93,//&3'-:
~~~
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Date of Application:
Receipt II: 9S;J"::!I
Total Amount Collected:
8-/t:> -5"31
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