HomeMy WebLinkAboutPermit Plumbing 1995-9-19
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OfFICE. 726-3759
INSPECTION LINE: 726-3769
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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:
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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. .
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SIGNATURE Y /
9- /9- 9')
DATE
FOR OFFICE USE
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DATE OF APPLICATION: .e:y~~
RECEIPT 11: /'~='-:> ISSUED BY:
TOTAL AMOUNT COLLECTED:
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/'/ JOB 11: ""'YC)'./<;"./~
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