HomeMy WebLinkAboutPermit Plumbing 1996-3-28
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BACKFLOY 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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OYNER:, 'floX/~ ()c..-I~ -
ADDRESS: I? 9?/ Car~:~?.ei'
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PHONE #: 7~b-~.yy
STATE: 6A ZIP: C; 7/777
BACKFLOY PERMIT IS $15.00 + $~75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRAcrOR: S:lj~~ 2&€- b;;:y'~~~ "
ADDRESS: 4-"~6"60 '/!1:~~A.?/~ 4/ ,PHONE #: ,'7~~ 7d
CITY: y-ld/ STATE: C)/?
CONSTRUCTION CONTRACTORS REGISTRATION #: 0"663
ZIP: 974'?=lj
EXPIRES: ,11-/97
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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SIG~ATURE' .J, - V
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DATE
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FOR OFFICE USE
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RECEIPT #:
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ISSUED BY:
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, DATE OF APPLICATION:
TOTAL AMOUNT COLLECTED:
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