HomeMy WebLinkAboutPermit Plumbing 1995-5-19
SPRIN~\i~LD.,"",,,, m '
~;;i:i
_' ,BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
I' CITY OF SPRINGFIELD
,BUILDING SAFETY DIVISION
225. FIFTH STREET II
SPRINGFIELD OR 97~77
OFFICE: 726-3759
INSPECTION LINE: 726-3769
, I
--------------------------------------------------------------------------------
'JOB LOCATION:
'""/!. ASSESSORS MAP #:
)~/dL/ C.aYY1~d',\ e Plo:ce
/7121 2-S 2-1
,.
'fAX LOT #: /~ ~(X:)
I'
OWNER: </ Gold ! L {A c.. 01 S
t
ADDRESS: J 7;JL/; LOrYY)'Pl'3-P-. ,PfC>1Le
CITY:. SfYl-YljfeJd STATE:
Ii .
PHONE #: J 47- 0'7; S /
DR ZIP: 07l.}77
BACKFLOW PERMIT 1'S $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
.'
()Wy\<iY-
'.t~c-
I
PHONE #:
CONTRACTOR:
ADDRESS:
CITY:
j,:,
STATE':
'I .
ZIP:
CONSTRUCTION CONTRA~TORS REGISrRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL F'OR AN INSPECTION ONCE THE
BACKFLOW PREVENT10N DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I AU SO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS,
CORRECT.
, "
. '-X "-1 odA 01 ,'lUA'~
. SIG~RE
5 -I q -4 S
DATE
FOR OFFICE USE
, '
L . .
--------------------------------------------------------------------------------
I
j!
DATE OF APPLICAT]ON:
" I . ,.,
RECEIPT #: /744':s
TOTAL AMOUNT COLLECTED:
'S-05'hF '
/ /
ISSUED BY:
J(;. ?{)
JOB #:
.~Py~
:7 s ~<f::; 8:,
---------------~~--------------------------------------------~~-----------------