HomeMy WebLinkAboutPermit Plumbing 1995-10-3
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BACKFLOY PREVENTION DEVICE,PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING ,SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: -?tJrJ'Z) if/l/#?M/A' , 5~/?f~~/~LV
" ASSESSORS MAP #: 1'162.. ~S J~ TAX LOT #: 05 0 II
OYNER: . /27f)hlrrl-v~ /hf24//A-g/
ADDRESS:' -~J3~/..}j;U.:;.(fi,~~ >>~. PHONE #:
CITY: I.l)~ /J~c)'o (0:w, --. STATE: m.
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ZIP: ~4cJ6/
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:eh~-7 / /;:JJ~;C;,('//~
ADDRESS: ~~92Z ~--4-;;E~ ~t7P PHONE#:
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CITY: /~~~~ STATE: //1- . i
CONSTRUCTION CONTRACTORS REGISTRATION ~: /c?/3 /;;2 3> sf:::
, 6/ &6~7,
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOYPREVENTION 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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ZIP: o/7dJ6
EXPIRES: /'7/?:
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f/illJu'~ $~~
SIGNATURE v ,I, .
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DATE
FOR OFFICE,USE
DATE OF APPLICATION: ,b... 3- g5 JOB. #: LiStS &5 ,.
RECEIPT #: Ol q IRS ISSUED BY: N - (\/\' '
:rOTAL AMOUNT ~OLLECtf l ( 0 . )1)
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