HomeMy WebLinkAboutPermit Plumbing 1996-6-27
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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
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.' ASSESSORS MAP #: 17 () d- 31- q Lf
OWNER: r;;.w VA.-! W,c;-c;J/ eft--
ADDRESS: / 20 S- f LE::~~ rr-f en..- L.J./.
CITY: S~ PGt) ,. STATE: ({) It -
JOB LOCATION:
TAX LOT #: DO XiI
PHONE #: ? Z<::, -:::> ':::J h 0
ZIP:-.q lcV.b
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: .MM:rr,J ~A-5 {!;eJ L1.1.JC
ADDRESS: Y;7Zg-~ T~I ~(~ ~ ~ _ PHONE #:
CITY: 1) P~T~ STATE: (\:).f'L-
CONSTRUCTION CONTRACTORS REGISTRATION #: L8L- &30.>_____
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3 4-~ ~9 '34-l
ZIP: Q74k-C
EXPIRES: t) ~ f Co
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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lsIGNATURE . lJ
b~ 2-7- j{o
DATE
FOR OFFICE USE
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DATE OF APPLICATION: (I /~ 7/ '1 (;:l JOB.: qc:;/ (, r (
RECEIPT D: 0 'd-?-cry l' ' ISSUED BY: Ii JYiQaf, Qp.!() .
TOTAL AMOUNT COLLECTM/: 10 < m