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HomeMy WebLinkAboutPermit Plumbing 1995-6-29 .. - .' ..'~~". 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: -z 7~ 6~h6" .r~~ . K.z:> . . 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~. I" TAX LOT j1:~/,~ ~'Y')-~ . . 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. .. Q .-7 T/ 7--7' NATURl 'I '7 ~ -Z-'??::? DATE FOR OFFICE USE DATE OF APPLICATION: b-~~ JOB j1: 7:-7cP'7c:::;-' RECEIPT j1: /??, /'Z~ ISSUED BY: ~~.. . //. -:>~ /: --- TOTAL AMOUNT COLLECTED: ~. ~ .