HomeMy WebLinkAboutPermit Plumbing 1994-8-25
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BACKFLOWPREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: '70 3 ~
ASSESSORS MAP #: Lts "7-
OWNER: '\6 (1/ ~ t.3enT5
ADDRESS: d-..O 0 C (( cGTfl/tPI\J r
CITY: 'Stlfl/ L-V'l.l'5 0 r;; I sfo
CA. ~ ,./(i-4..
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t( C#7qY//E /p/tAX LOT #:
STATE:
PHONE #:--E.05 - <'-l3- Y II S;
/"......A ZIP: .23'4 <.) L
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR:. (<.\.~TW~ Pl{,un~(A.lf-..f- 13,{:., ~tLv,
ADDRESS: ~ P (). 80 x. 7D~?-ro PHONE #:
CITY: 6lA h.f!)-J 0 STATE: OfL-
CONSTRUCTION CONTRACTORS REGISTRATION #: Uo, ....-b I
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J..j f/4- 37 <if; 7
ZIP: Cf7'l: () I
EXPIRES: 1;)...--/ b -C( tf
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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FOR OFFICE USE
DATE OF APPLICATION: 9~2S-9C/
RECEIPT #: I ~ '/5:5 ISSUED BY:
TOTAL AMOUNT COLLECTED: /6- . 2c:>
'/J JOB #:~;li;~~
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