HomeMy WebLinkAboutPermit Plumbing 1994-8-25
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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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JOB LOCATION: 7 D I (p
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ASSESSORS MAP *: /? "r!!)7 - ~.5'.... ~ ~
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OWNER: 'K D,J t2-o he_a...- + OS
ADDRESS: 2' c>t::::' c:~c ~ 7 /??~~?-
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CITY:~#N/V/:~ ~r'7~- STATE:
TAX LOT *: ~5/tt!>C?
PHONE #:~5'''' ~- 'Y//S'
~ . ZIP: 9_3.~e>/
BACKFLOW PERMI[ IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: K''1VJlJw~ 'plu n1kl;VL~ _ d-~. [:, S~ v.
ADDRESS: Pt7.. ~r"7~_"5"-2~ PHONE #: ~~05?8?
CITY: E~~~r- STATE:?/~ . ZIP: ~_;.~/
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CONSTRUCTION CONTRACTORS REGISTRATION *: n , .-;, ,.;",... ~ EXPIRES: /2-/6=-~ ~
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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SIGN~:RE
ff/0-.;-/7 y
DATE '
FOR OFFICE USE
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DATE OF APPLICATION: ~ -<'5"". '""7'7
RECEIPT #: /Y'7'91S- ISSUED BY:.~
TOT,AL,AMOUNT COLLECTED: /6..- ,<0
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JOB #: 4.-;;.1' 7'~- '2' ~ '
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