HomeMy WebLinkAboutPermit Plumbing 1994-8-25
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BACKFLOW PREVENTIO~ 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: 7 ();)- ~
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, ASSESSORS MAP #: _ /? -c:!:>2. -~ 5'"...,'/ "3
OWNER: ~ Y\ ~1~A1\ So
ADDRESS: 0100 e r1..€.St-/11 0/111
CITY: So"y! Lues ob: Sf') c;:> STATE: t!:A
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TAX LOT #: ~5"'~o
PHONE #: ?oS -S-tC3-. <...f./lS-
ZIP: Cf 3'f() I
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ifZJ~~ ~,bJ'^d ~ (3,c.. ~UlCC
ADDRESS: tJ ,0. 130~ '7 0 ~;,....Co PHONE #: Lf~ -l.)6-"/
CITY: 9AJO ~ Q STATE: CVL ZIP: or 7 <fcJ r
CONSTRUCTION CONTRACTORS REGISTRATION #: 47~~ ( EXPIRES: I ~ --f6~ C( Y
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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SIGNATURE -
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DATE
FOR OFFICE USE
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DATE OF APPLICATION:-.B L'7 ~
RECEIPT #: I ]lC(?~ ISSUED BY: 4~,
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TOTAL AMOUNT COLLECTED: ~.~
JOB #: ~V~YB~
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