HomeMy WebLinkAboutPermit Plumbing 1999-10-11
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SPRINGFIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 't~...f A- s -r: '5c1~D
" ASSESSORS MAP 1I: 17 t;"3 J S L;z.
mINER: \ j l e.&-t L 1ft<:. v' ( c..t<:eie,
ADDRESS: 3o~ ~~u,J..g~.uu.- wY PHONE 1I~ 2-o'1~-lfnV
CITY: c,jPp; I'~ M.olJr;;;i"!;ro STATE: ,('..!J:. CAt-# F ZIP:..., ~ T , r'
qS3~
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50
fJ.o, '7~, A V
TAX LOT 1I: . O(':)UU
CONTRACTOR: Tc..J ,AJ R.,t./~ P~If!:.I.,.,v/~
ADDRESS: I S'~ It:-vu../6- tU:> PHONE 1I: t8 g- - ( LftJ4--
CITY: GU-G-e'pG STATE: orZG' ZIP: Ci'7<..ff>'-f>
CONSTRUCTION CONTRACTORS, REGISTRATION 1I: 11ft;> '1 ~ .. EXPIRES: t:>('Unro
"r Il::,,,,v"'-'-~db theOregonU\,:lty I
follo~~,~le~~~~~:eThJse flJleSare se! fo;: .
BY SIGNIN~f:~!I~,$~ J?1?~~H!c~\,~!:'y,:H:A!J:[ON'i'5[.('A~REE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOVI 'PREVENTION DEV.IC~LHASoBEEN'l!l:NSTALLED AND IS VISIBLE FOR INSPECTION ,
(726-3769l)1!). ~FuA'USO C'S1:ATE'o'f!i~~eAliliP]NFORMATION ON THll'llO>ltdm'1 APPLICATION IS .
CORRECT call1na the cemel. \" ''I'' Notificatior
. ,",umber for the Oreg~2 ~2~ "L, Ill,\, THIS PERMIT SHALL EXPIRE IFTHE WORK
rn_'~'" AUTHORIZED UNDER THIS PERMIT IS NOT
COMMENCED OR IS ABANDONED FOR
ANY 180DIW~if1If)D1 q if
DATEf
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SIGNATURE
FOR OFFICE USE
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DATE OF APPLICATION:
RECEIPT 1I: !') 3. ~~ 3 J
/0/,t/10,;
TOTAL AMOUNT COLLECTED:
ISSUED BY:
N...S~
d/JJ
JOB 1I: Cf 9/3 8'5'
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