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HomeMy WebLinkAboutPermit Plumbing 1995-9-19 - . BACKFLOW 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' ;1~ 2 ~~ ASSESSORS MAP 11: /~""9f ~ - :z../ OWNER: ;;;;;r-/ I'.-r/' k~.d'/~ ADDRESS' .7fl3;) (lk;)~ .t)t,'/~ CITY: ~C:IA. STATE: ()/C BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 TAX LOT 11: ~;:1<-~ PHONE 11: 7-/ (tL.!{::J;;) ~ ZIP: 971..{?l CONTRACTOR: ~J2 / (J. nov-Q...... Ode:, ADDRESS. PHONE 11: CITY: STATE: ZIP: CONSTRUCTION CONTRACTORS REGISTRATION 11. EXPIRES: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL fOR AN INSPECTION ONCE THE BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769) I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. . ~~ L~L SIGNATURE Y / 9- /9- 9') DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: .e:y~~ RECEIPT 11: /'~='-:> ISSUED BY: TOTAL AMOUNT COLLECTED: ~_2'? /'/ JOB 11: ""'YC)'./<;"./~ ///~~ "if" -~ , - --------------------------------------------------------------------------------