HomeMy WebLinkAboutPermit Plumbing 1998-4-15
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BACKFLOIl PREVENTION DEVICE PERMI'!:\~ATIg~p..\.\.I:.~ ~S?I:.?~\\ O?
CITY OF SPRINGFIELD ~ I:.?~\\ I:.? \~ ~I:.\) r
BUILDING SAFETY DIVISI~\S? ~tl:.\) \)~\) p..~p..~\)o
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225 FIFTH STREET p..\.\ ."~,,,~CI:.\OF'F~t) 726-3759
SPRINGFIELD OR 97477 ~gPm:T~\'lN~E: 726-3769
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JOB LOCATION: J f q 'Z. C!.-t!3NT~1 AJI 4 L
ASSESSOr,S lu\P #. I -(O:S2.'S 3L/
TAX LOT #
19D 0
OIlNER: ANz-1.cA-<r ( ^-i (/~ 1~"T5
ADDRESS: 6-5S'"'O OA f<-.tlLrD~T
CITY: ~ ~l?
u/4'( PHONE #: Lf-gs;- tf-7lJ
STATE' 6r'C2? ZIP. '1'7 l.(-O (
BACKFLOIl PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: TVJ, k.) te..t tlE?Te-S pU..{j,.Lgt Aj 6-
ADDRESS. (S?-:s- (~(/ (N (, ~ PHONE #:
CITY: G-cJ..&EpJC STATE: ()~
CONSTRUCTION CONTRACTORS REGISTRATION #: (1 f, 'fr
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ZIP. 97l.fO<f
EXPIRES C, /9 g"
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOIl PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE
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Y-/lsY'7 r
DA'DE
FOR OFFICE USE
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RECEIPT #. ()14 LlLlli
TOTAL AMOUNT COLLECTED:
ISSUED BY:
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