HomeMy WebLinkAboutPermit Signage 1997-2-18
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SPRINGFIELD II
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225 FIFTH STREET
SPRINGFIELD OR 97477
BACKFLOY PR~VENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
OFFICE. 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: /80D CeNTeNNIAl-
ASS~SSORS MAP 1I 17032..53 'i
OYNER, ;./ L:::,T~ LlJiAf2-t1 DVI (2.6e
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TAX LOT 1I: 03 7m
ADDRESS' / ~Oo CJr-"rrtENA./1 AI 8U/p. PHONE 1I:
CITY: _ ":3:otz live;. (?I eL i\ STATE. ()fL
ZIP: 9 7</77
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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ZIP' 77<(02-
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CONSTRUCTION CONTRACTORS REGISTRATION 1I: S- I 3 0
BY SIGNING THIS P~RMIT/APPLICATION, I AGR~~ TO CALL rOR AN INSP~CTION ONC~ TII~
BACKFLOY PREV~NTION DEVICE lIAS BEEN INSTALLED AND IS VISIBLE rOR INSP~CTION
(726-3769) I ALSO STAT~ TIIAT ALL INFORMATION ON TillS P~RMIT/APPLICATION IS
CORRECT
;<-/ ~- 9'7
DATE
FOR OFFICE US~
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DATE OF APPLICATION: 2 -It ,.q "7
R~CEIPT 11 2.. "I~'fq ;SSUED BY. ~
TOTAL AMOUNT COLLECTED: Ib.:2.[J
JOB 1I: Q7>>J../dL
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