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HomeMy WebLinkAboutPermit Plumbing 1994-8-23 o ~ BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 F1fth Street Sprlngf1eld. Oregon 97477 Off1ce: 726-3759 INSPECTION LINE: 726-3769 Assessors Map II Owner' ~u. ("'~"'" 5-\-CLG.-k.. Address' 'L\ 4<Z CCV\--\ClA<A.l,,< \ C 1 ty' <('OC l~< ~\e: \ .L. State \ l "-LJ ~q Cc"''+~'''',^'4 \ \'l{)3~~1~ Tax Lot II. n~~ Job Locat1on Phone II' l Y L{ - ~ "2. \ \ o~ Zlp. Backflow Pen11l t 1 s $15.00 + $0.75 State Surcharge T ~ O"?o Clty: Ou":;,'" 1-,,,"1. \. ,,-\.-......:. 11 L ~ S'-'-- ,-.A ..-vL. L.-.c., v-.L.. Phone D: <T""1.e- State: O\"~ 5\\1 ~y,- l~ \('<-- Zlp: 91'-( (f(,.../ Contractor' Address Construct1on Contractors Reg1strat1on D' Exp1res' By slgn1ng th1S perm1t/appl1cat1on. I agree to call for an 1nspect1on once the backflow prevent10n dev1ce has been 1nstalled and 1S v1s1ble for 1nspect1on (726-3769). I also state that all 1nformat1on on th1S appl1catlon/perm1t 1S correct. " " 9~ <6, - ()-l~ Date FOR OFFICE USE Date of Appl1cat1on' R A~ ,Cf4 Rece1pt II 1M ~~ Issued Total Amount C~llected~ \~ qLt \?~2-. ) i ,