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HomeMy WebLinkAboutPermit Plumbing 1995-5-30 r' .. . ..' :~. , SPRINGFIELD BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- ~ ~ :3 <? ,l)4/J~L~ /~/4'. , ASSESSORS MAP *: /6~.2~t::'4-4>C:a OIlNER: ~Jf~/~~4#~.::::r~ ADDRESS: 73 y';;'p .i?t1'~... J ~. PHONE *: CITY: ~p~vz::>_ STATE: /:2 ;~'. - , - . JOB LOCATION: " TAX LOT *: ~~;~ '") r /-~S,e:5~ ZIP: q;J 7?g- BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 .' /'? VY'A7~?~ l../ .. PHONE *: CONTRACTOR: ADDRESS: CITY: STATE: / ZIP: CONSTRUCTION CONTRACTORS REGISTRATION *: EXPIRES: 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. , SIGNATURE (),~ V 5r-3()~ 15 DATE FOR OFFICE USE RECEIPT *: /7 "5'~ 7" TOTAL AMOUNT COLLECTED: ISSUED BY: JOB 1I: -95'~,/:::> /7~~ - ~.;----....--- DATE OF APPLICATION: ..,-- ':/t:'- ~