HomeMy WebLinkAboutPermit Plumbing 1998-12-29
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DACKFLOII PREVENTIO~ DEVICE PERMIT APPLICATIO:I
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIE::.D OR 97477
JFFICE: 726-3759
INSPECTIO:i LINE: 726.,3769
______________________________________________________________ on _ _________ _ .. _____
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" ASSESSORS MAP 1\: {10-3>3 5 ')):t
Ol/NER: ':C;;ri'Al"/>I"/d #~;//ju
ADDRESS: f 01 ,#~ 3t'.7ZJ
CITY: p/r/~/h"'/d
TAX LOT dO / 00
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JOB LOCATION:
PHONE 1\:
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ZIP: f"7~7/
STATE: ~/"
ATTENTION:Oregon law requires you to
BACKFLOII PERMIT IS $15.00 + $.75 (STAftltJo~<:UQteP~.111il(QMncmlUti~) = $16.20
Notification Center, Those rules are set forth ',i
jp OAR af;2-001-001 0 through OAR 952-001-
C;ONTRilpTO!'j:_U/4~~ /}buY ~~ell'J.rr;'SOlf-.olifM; cnniA" of th~ hv
, ' ; calling the center, (Note: the telep/jol)e -' L .:i'? t:::;'
ADDRESS: f? /2- 1/ <;,f- , ,n"mh"r1Mth"n~ftyll!ot~"-- f?..hr-7
CITY: -:>",,""/ZIbJ:,,"r! / d STA'tlrier iSJ'-POO-332-2344). ZIP: ?7q /'.?
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CONSTRUCTION CONTRACTORS REGISTRATION 1I: /2 b c:17.) EXPIRES: //- s- - o-t?
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. SJ.GNATURl:.
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN::?ECTION ONCE THE
BACKFLOI/ PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE :')R INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT, ,\PPLICATION J10'r.'t-
CORRECT. ' f ,y.~ 0'
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FOR OFFICE USE
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RECEIPT b 'O.!o 1.. tf () i { I ISSUED RY: f( -M ~
TOTAL AM(IUNT COLLECTED: ,1; 1(; -1-0
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