HomeMy WebLinkAboutPermit Plumbing 1994-4-26
.
.
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
#4D
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
.
Job Location: G\?/ fJ yo. U\ '-~y \< tc) tfL-:;
Assessors Map II: \ ~ Cy~ 2-1\ f4\~ 1ix Lot II: CYJn~ ~
Owner: ~ ~\'\0 .}~ \~,(CJ\ Aye, .
~ -::j.,\ .. u() I(VI .
Address: qOZ).) ffi t \H ~ T~L\/ _Y Phone H: HC'D c<j1(n
City, ~?Qq & . Stot,,<\\,)~ t~(m ,,~,..9!1t1J
Backflow Permit is $15.00 + $o.75~tate Surcharge
Contractor: ~tJL~_o~~
Address:
City: <;tate:
,j .
Construction Contractors Registration H:
Phone D:
Zip:
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 application/permit is
~
FOR OFFICE USE
-
Date of Application: Lt-.J!.)o/-Lff ( A Job D:
Receipt H: \&4C{ ~ Issued ByCl)I [\/),,-
Total Amount Collected: I ~, rL ~ . . .
f408'{( )-
'"