HomeMy WebLinkAboutPermit Plumbing 1995-6-29
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SPRINGFIELD
BACKFLOII 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:
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. ASSESSORS MAP j1: /'/'0 ~~.z-Z- Y 50"
OIlNER: 'U:// 0#7 E..?r
ADDRESS: -;z '/70 0-'T/...........<!'" ~ /i.b PHONE j1:
CITY: -5' ,;t:>;<:,c..z::>.. STATE: t!9~.
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TAX LOT j1:~/,~
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ZIP: 9:./"7'/7
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CO~RACTOR: prcrn- ~;tJnr- ? ~7f/~c=---; /;0'L ,
ADDRESS: -5'ZC:;- /f(e>~...y ~. PHONE j1: r:-~?-9/>4;/
CITY: &~~ STATE: ~. I ZIP:~~
CONSTRUCTION CONTRACTORS REGISTRATION j1: 6' 2€ii?? EXPIRES: /<-?~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOII 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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DATE
FOR OFFICE USE
DATE OF APPLICATION: b-~~ JOB j1: 7:-7cP'7c:::;-'
RECEIPT j1: /??, /'Z~ ISSUED BY: ~~.. .
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TOTAL AMOUNT COLLECTED: ~. ~
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