HomeMy WebLinkAboutPermit Plumbing 1997-5-16
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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" ASSESSORS MAP ~: \ 1 cJ~ ~~ TAX LOT ~: tJ4-~ci)
OIlNER: t r\ 0 \ Q f\ \\u ~ 3J'(\
ADDRE~1(\ oN - \ , 3\1 "tPHONH l ~, \nqql q .
CITY: ~rtSTATE: \~\G~Y\ ZIP: C\l411
BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTO~(jJJ) <u. V"\ \ ~ \.A t' 0 , . .
ADDRESS:\ \J l Q ~JL C\ \ C\ \ () PHONE ~: '-1\-{n, \1& J
CITY: rLC\Lv\ L . STATE: (or OC\flV\. ZIP: qr+if)
CONSTRUCTIOrh:ONTRACTORS REGISTRATION ll: n()(rll~-' - EXPIRE}: \0 .~\ .C\ 7
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOV PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TlIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
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5-/0- 77
DATE
FOR OFFICE USE
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TOTAL AMOUNT COLLECT~D: \ \n . ? l ) ~ - -
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