HomeMy WebLinkAboutPermit Plumbing 2002-1-4 (2)
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SPRINGFIELD
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DMSION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Job Location: 2-23 11 'ST, SPf?JN(;J:/l-tVt? ,f)V4.-Cj'7Y 7
Assessors Map#: 1703'S 5';' L.TaxLot#: (') ']0" a
Owner: 5P~\ t.)bF-t aD vr I L 1-rY .ry)~O
Address: sA", ~ ~ 'f! If 51. <.9/Z-t,..Jt:!:=/{J"Lt) Phone#:
City: Sfe..u.)t..A"W State: p? Zip: fllll
BACKFLOW PERMIT IS $51.75 (includes Pennit Fee, State Surcharge & Administrative Fee)
Construction Contractors Registration#:
State: IJI?-
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Phone#: /; f j' - 7/ It/
Zip: 9' 1f/O 1/
, Expires: f.."hoJ02...
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Contractor: /)[L.rJt lltrv'OS' WIT ...J.
Address: S?-~ J./vN W.
City: p"'1(t:,,6~J.K"
By signing this pennit!application, I agree to call for an inspection once the backfIow prevention device has
been iostalled and is visible for inspection (726-3769), I also state that all information on this permit/application
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Signa~ Date
FOR OFFICE USE
Date of Application: 0' - 0 C( - 0 L
Job #: 0/ - o/L(3/ - 0 I
, Checked for Delinquencies:
Checked for Historical Status:
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VALIDATION: '
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