HomeMy WebLinkAboutPermit Plumbing 1998-7-20
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SPl-F'ELD
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NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK
AUTHORIZED UNDER jiWl:Sdi~~6~1:P16:~TION DEVICE PERMIT APPLICATION
COMMENCED OR IS ABANDONED FOR CITY OF SPRINGFIELD
ANY ~OILDING SAFETY DIVISION
180 DAY PERIOD. ..
. 225 FIFTH STREET' OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: 1-.5--3.6' CI1A/4t....
.' ASSES SORS MAP #: / 1 (J 3 Z-l(2- t?
OWNER: Ell../s~;../ ~ /c!;<J!2
ADDRESS:
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SP~^,e; ..;; ~, kCJ fJ/
: 0100/' TAX LOT #: 0/00 I
C"_rST4c/rc.,;
PHONE #: '3'<;;(- Yb~ .;-
CITY:
STATE:
ZIP:
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: J-.J u.~ ~ L ;.,f AJ,t?/9 /.b -v. if
ADDRL3S: -2tS-.;2.. ^ C S / ~;9"--~,?~" ..< ~/
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CITY: /~,,, '-<. / ..,.". STATE:
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PHONE #: /...l.)- 8:z../J""
,<y rt:. ZIP: /? 'r 8-7
CONSTRUCTION CONTRACTORS REGISTRATION #: II.?"?;)
EXPIRES:~-~-J;9
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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S~\ TURE
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DATE
FOR OFFICE USE
DATE OF APPLICATION:
RECEIPT H: 6s Dct{ 7
,
7/Zvj ~
TOTAL AMOUNT COLLECTED:
ISSUED BY:
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_ ;lOB #: Clc:;o I" 7-
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