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HomeMy WebLinkAboutPermit Signage 1997-2-18 . SPRINGFIELD II ~ 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 -------------------------------------------------------------------------------- / JOB LOCATION: /80D CeNTeNNIAl- ASS~SSORS MAP 1I 17032..53 'i OYNER, ;./ L:::,T~ LlJiAf2-t1 DVI (2.6e . - 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 CONTRACTOR. (~) ,^-IS<"lC LAI\.I 1\SCA 013 i i !:IZ/Z.{(SI4.-not0 PHON~ 1I: 0>N 0'92 <-( ADDRESS, /7/ (;;J /.-11: ~ CITY r-s-u r-,fSA) r:- STATe: o(C ZIP' 77<(02- ~XPIR~S......."'f/3~/'17 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~ -------------------------------------------------------------------------------- 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 --------------------------------------------------------------------------------