HomeMy WebLinkAboutPermit Plumbing 1998-9-15
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SPRINGFIELD ,{; ", ,,' ~., \.S]("
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCAT~ON:
/5"05" ~~' k
ASSESSORS MAP ~: . /7 () ~ -:3 t.f 2.2.;
OWNER: d;~/faII1J'7i11 ~Jh',
ADDRESS: ~::;<g70 . r~(>r2(7T r2v PHONE #:
CITY~~If"'J---r )..fu..e- STATE: ,,12-
TAX LOT :it:
6 d'5 67J
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BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: C~/~~ ~/rt'7
ADDRESS: //fPlJ LPJ?/~~ PHONE #:
CITY: ?d~ STATE: t!J#-
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CONSTRUCTION CONTRACTORS REGISTRATION #: /~Z71J
rt./j(o~1J 16
ZIP: ,?Y~d~
EXPIRES: Irq
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL,FOR AN INSPECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND is VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALLA;rNF.QR111ol1)m~~gQN THIS PERMIT/APPLICATION IS
CORRECT. ..N to!/?W ~U!es adoPte~b law requires you to . '
, oM/calton Cent -, Y the Oregon Ut'"
In OAR er. ThOse / IIty %
952"001-001 . ru es are set f
0090. You m ? through OAR 95 Ort "
calling the %~~tatn copies of the ruf-OO j
nl 1mhAr 1-or tJ _ er. (Note: the te/epJ 17 I f g-
'e uregon Un 'B E i
Center is 1-800 33 Ilty Notification ,:
- 2-2344).
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SIGNATURE v\:-
FOR OFFICE USE
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DATE OF APPLICATION: q -tS - <1 '-<
RECEIPT #: "$(l/=?r ISSUED BY: .t&.J
JOB #: :crr' OL/ft"rr'
TOTAL AMOUNT COLLECTED:
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