HomeMy WebLinkAboutPermit Plumbing 1996-8-13
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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:'t~ ~L DcVl...,^ cC k~
, ASSESSORS MAP #: \\\)~~\~ TAX LOT #: ~
OWNER: 'M{\. ~~C:L \2o~
ADDRESS: l ~ ~ 7- ~V'\ I/\. '\ <- ~'-L PHONE #:
CITY: S\f'C''':'1 ~\e ld STATE: (j\(~ ZIP: C{1 L-l"11
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $,45 (ADMIN, FEE) = $16.20
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ADDRESS: L (L l..o ,~"'^ lM.ref Lu.v...f.. PHONE #: '5~ (r ~~( <) -\4<6"<--
CITY: ~1-e.-.- STATE: OR 0 ZIP: q-C....-\(j.....(
CONSTRUCTION CONTRACTORS REGISTRATION #: :)~ L ~
CONTRACTOR:
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 PERMIT/APPLICATION IS
CORRECT.
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DATE \ 1
FOR OFFICE USE
ISSUED BY:
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>J.., JOB i: Q\O\ \ \ \
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DATE OF APPLICATION:
RECEIPT #: a~~~
TOTAL AMOUNT COLLECTED:
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