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HomeMy WebLinkAboutPermit Plumbing 1998-8-31 BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY-DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- , JOB LOCATION:-1G2J ("':tt.\JTENNlL t?.L\Jb/ ~'~r\U.D .' ASSESSORS MAP #: ~~N \~(J3Ao~~ TAX LOT #:..JA>KlY-NJN r;\~-fi) mINER: N\r.\e~~ Wl~'lL ~-t:t1OL t"rJJT'llu\~~~ CJJ~ ADDRESS: \"'-\ C;('J '\ c=( ~~ l PHONE #: ,--\ <\ . ~OC> CITY: ~\\)("\t-1ElD STATE: r-R ZIP: ~)f77 BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR:~~~ LA~ C0~ ADDRESS:~.,\~62. PHONE #: 6~G '~4.6q '~ '\.0' CITy:g~~~ STATE: ~."""~Iv+JC ZIP: q-) 44C> ~~hJ; ~ !i~u"" ru' IV:OIi =, )~~N~CTORS REGISTRATION #: \~CatirJ.~~adO!J:~f/Jiv~:: C..20.<=Jl) ~/\ (.;10 ~(L'- 0090' Ii 952_0 enter. " by the qUires 0.... v o^ V<<,^"~ ' . g:YO o~_ rl:t hos Ore YOu t BY SIGNIN(t..<T.~V.J'lm)l-lT~PLI,CATION, I AGREE T8.CgllA:,}, :JI, I~I., .a~'MlT'lIOOfft>>$ BACKFLOY PR 't~'f$~_IAS BEEN INSTALLED lJm.tJel-j ~~ LCW1EQ .~<< iG~t. " (726-3769). ~L~& .y~T ALL INFORMATION ON rrtt176l'S~Mr/tl, , JJJ ~:i,gl1h' CORRECT . V1t~ 7)' 4-0..0 ' enter is 7' SOon U/.: ~he tele e rUles b 7- <> ~ .{s1 ~ 'r.r -800-a3.~llty IVot.''fhone ~ 0..0 V,., <-<'':>A l'ICal" , 'T / u~~ '~ (' ,)~ .~ \8.~1.<jfl, SIGNA~ -~ DATE FOR OFFICE USE -----------------------7)----------------------------------------~-------------- DATE OF APPLICATION: '1' . g. q g r I JOB ft:!J!1Lf) Loa RECEIPT ft:, (~L::><<\ ISSUED BY: CJ\(~ " 1(0 ./J/) TOTAL AMOUNT COLLECTED: -------------------------------------------------------------------------------- ""-,