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HomeMy WebLinkAboutPermit Plumbing 2001-10-4 . . BACKFLOV 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: /b07 bod", 0. r<fI1At!JWd. OR- 17177 .' ASSESSORS MAP #: TAX LOT #: OVNER: /2Ji el<:l(? ~/-rJ4u~i - I {/ ADDRESS: tho 7 })1>t0~ tn CITY: ,C'J1M1hdd '/' (j v PHONE #: 71/7 -33h.~ . ZIP: '17<177 STATE: tJry JfYJ BACKFLOIl PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $SI.7<;: CONTRACTOR: CC)-k" Ldvrd('(~ 1/1A:1.. ... .... , . ;. v ADDRESS: 93?U, i2< 're.... M. CIT;: ( kC!.ntr/ C: ~ u CONSTRUCTION CONTRACTORS REGISTRATION i: PHONE #: STATE: . ;(j~tjtV) & / cfG. \ C/9t' '~.3 q ZIP: 17t/</rf EXPIRES:_7,......2%-02. BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. oI~~~L Ul:l:GNATURE ~~cLt ! DATE D 1-d7~{)( FOR OFFICE USE ---------------------------------------------------------------------------~---- DAT~ OF APPLICATION:.. ./0/0 '1/-= t. ... RECEIPT #: b lOI / ISSUED BY: TOTAL AMOUNT COLLECTED: 51 ?...>- . JOB #: .ot=.DJ09l-91 :D ::!t -< -< 0 ::0 :D :D ::0 .....z f'T'I"" C1J 0..# ("'") co.. D .. no ----------------------------------------------------------------------------~- ~~~ ~C")woo fT1 ::c ~ 0 ;uDU'1 0 ..:z.....f'V0' 0(;').0....0 O"-I"T1-.Joo t-4 .. t.T1 t-l ...... 'bf!,.