HomeMy WebLinkAboutPermit Plumbing 1991-7-26
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SPRINGFIELD
OACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
OUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location: Lf341 Elck{be.((U~-r
Assessors r~ap D: /762..3'2.34
Owner: SCOIT ~ ..JANET 1<ATI-h~CN~
Address: L-\ 04 'l eLl~e'l<..\3EJ<.""\I oSl
Tax Lot D: [J57DD
Phone #:
72~ 8'W-f
Zip: q7475
City: 5~ll>Jbn8-0
State:
Of--
Oackflow Permit is $15.00 + $0.75 State Surcharge
Contractor: Ou.J M::R-
Address: ~.
City: State:
Phone D:
Construction Contractors Registration D:
Zip:
Expires:
Oy 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
correct.
...JO-Mrt H ~~-
Signature
7-2.Io-Q/
Uate
FOR OFFICE USE
Date of Application: !. -7-./0 J1! (\l~~b_:: Lflo?56''Z.-
Receipt II: 7(:J'6'Z~ Issued Oy: \jjv~-------
. .
Total Amount Collected:
10-1..0