HomeMy WebLinkAboutPermit Plumbing 1992-9-27
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: I~I c;;:). A S+
Assessors Map II: )JO~ '3-,<:=;2:.:::1 Tax Lot D: OIol<OO
Owner: .A f'"r', Y'\? q PrO... c:b.r.pn-L
Address: \7)\ :S. A s..+ Phone II: 'ILf 10- ) ~ I
City: A..pv'I\"'JR jj{ll State: r)R Jip: qjL./J'
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: \AJc.."tlA) ':R'.r-fL..> TVV~Cl\+\lJV\
CJ
A~dress:J 0:;0 g~ :70 z-s2..
Clty: -r ~l-e.?'?~ State: a~
Construction Contractors Registration D; ~~ ~~
L(;./J r
Phone II: ;Y?~ -7~ /
Zip: ~t?/
Expires: i.2 ~
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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 all information on this application/permit is
correct,
lI;.:9/~ ~='"
Sign'ature
"'/-;)'7 /c,i
Uate
FOR OFFICE USE
Date of Application: It -7~j17.._-
Receipt II: In ~O Issued By:
Job II:
q ~/38'.3
~~
Total Amount Collected:
10.70