HomeMy WebLinkAboutPermit Plumbing 1998-6-22
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BACKFLOTJ PREVENTION D~ftl'~I~tuTHAPt~E~THE WORK
. . CITY OF snRl:fNCiFil~tb\:) At
. '. "..BUILDING SA~'-H~l'tmONDER THIS PE~MIT IS NOT
225 FIFTH STREET ~OMMENCED OR IS ABANDO~~~{?~ 726-3759
SPRINGFIELD OR 97477 I~NY 180 DAY PERlf)!WECTION LINE: 726-3769
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JOB LOCATION :..J t:) .2 0 _ C (; VI t7 Q ~
.' ASSESSORS MAP #: ! 7 oJ ~ if 2 5 D
OTJNER: A-;' ns.I.p, K\~
ADDRESS: <6.~g CrlS J- /)YI{ L-
CITY: (. Uf/tJ\.L. STATE,
TAX LOT #:
/00 I
PHONE #:
01L-
Lf3/-0/S 0
ZIP:!} 1@:s
BACKFLOTJ PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: -\-\, \ 1/\ ~ M2 (Ir.n' '1 (). tJ hV'. .{ L QV\ c-\ ~(' n \0 f) _
ADDRESS: 2":J7_/( 0 ~tvr'IL)\()JlVVI6 1....JA. PHONE #:'1.3.5-,--<;2'~
CITY:~J(\.s; \-FA~' STATE: (j)e. ZIP: 97L/~7
CONSTRUCTION CONTRACTORS REGISTRATION #: I {.3 7 2 EXPIRES: ~ ~, 9 '1
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOTJ 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- -1
zz.~lAV\~ 9S
DATE
FOR OFFICE USE
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RECEIPT #: J 30f..{J" 1" ISSUED BY: ~ 11/1?1 .-
TOTAL AMOUNT COLLECTED: :AI VI '" J-O "
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