HomeMy WebLinkAboutPermit Plumbing 2001-1-21
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BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
2.2.5 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 72.6-3759
INSPECTION LINE: 72.6-3769
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JOB LOCATION: ;tJl/;). s. A' S+
. ASSESSORS MAP II: 1703 ~ b S Z
OIINER: ~ Jfl U;~_
ADDRESS: 3So"Z- ,E:. ~"'_ &,..., U
CITy:_C;;F"'-;-'/~~ STATE:j9K
TAX LOT II: 0'-1 'CocI
PHONE II: . 7 J6 -1/6/
zIP:g7f/TZ
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR: 13::f;). ~ ~ dd-.-,
ADDRESS: 7:?s fL.. 14 AI
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PHONE II:
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ZIP : 9 "No z...
. EXPIRES: //ZfhZ
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STATE: Orz...
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CITY: ~"'P'".""
CONSTRUCTION CONTRACTORS REGISTRATION II:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(72.6-3769). I ALSO STATE THAT ALL INFORMATION ON THIS" PERMIT/APPLICATION IS
CORRECT. . .
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DATE
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. FOR OFFICE USE
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RECEIPT II:
'-(30(
00~1
ISSUED BY:
15$~
. JOB II: 00-002'6:::,--01
DATE OF APPLICATION:
TOTAL AMOUNT COLLECTED:
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